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Utskriftsdato (19.8.2017)

Colon and rectum cancer

Cancer in the colon and rectum are clinically usually considered as one entity. There are genetic grounds indications that right-sided and left-sided colon and rectum cancer can have different pathogeneses and appear to have different responses to treatment.

About 98% of all cancer tumors in the colon/rectum are adenocarcinomas. The rest are spinocellular carcinomas, carcinoids, lymphomas, and sarcomas. The tumors are often localized in the ascending colon, sigmoid and rectum, and rarely in the middle part of the colon.

In the embryo, the rectum grows from the abdomen into the pelvis. During this development the surrounding intestine and fat tissue (mesorectum) also "pull down" the covering fascias found in the abdomen. These fascia layers are very important for the dissection plane in localized rectal cancer.

Colon and rectum - Essential facts

Incidence

Compared to other cancers, colorectal cancer is fairly common and represents 8.0% of all new cancer cases in the United States. Colorectal cancer is most frequently diagnosed among people aged 65-74 and is more common in men than women.

The incidence of both colon and rectum cancer has increased in the past 40 years for both sexes. The incidence varies strongly between industrialized and underdeveloped countries. Changes over time and geographic variations indicate there are environmental risk factors. It is expected that there will be a substantial increase in these cancers in the near future.

 In 2017, it is estimated to be 135,430 new cases of colon and rectum cancer (18).

 

Age-specific incidence of cancer in colon and rectum cancer, 2010–2014.

Source: National Cancer Institute. Bethesda, MD, USA

 

 

Incidence of cancer in colon, 1975–2014.

Source: National Cancer Institute. Bethesda, MD, USA

Etiology of colon and rectum cancer

Most cases of cancer in the colon and rectum develop sporadically, which means that there is no known hereditary (genetical) disposition for the cancer development. 20 -30% of the cases may have a hereditary disposition as there is enhanced incidence in families or the cancer appears at young age. A specific genetic cause is known in less than 5% of the cases.

Hereditary forms

In about 95% of all cancer in the colon/rectum there is no known cause. The risk for developing this type of cancer increases with age.

  • Lynch syndrome, HNPCC (hereditary, non-polypous colorectal cancer is found in around 2-4% of all cancer in the colon/rectum. This genetic aberration is identified and may be tested in the patient and in uninvolved family members. The life-time risk for developing cancer in a person with Lynch syndrome is 60-80%. This genetic aberration increases the risk for developing cancer in the uterus (the endometrium) and ovaries, the pancreas, stomach, small intestine and kidneys.
  • Familial adenomatous polypous (FAP) constitute around 1% of cancer in the colon/rectum. Nearly all with this condition will develop cancer, mostly before 30 years of age.
  • Around 15-25% of the cancers appear in families with an enhanced incidence of colorectal cancer, without known genetic aberrations.

Sporadic forms

These cancers primarily develops as polyps. The majority of polyps will disappear spontaneously but around 10% will develop into cancer, usually within 8-10 years. The polyps which develop into cancer are either adenomas or a special kind of hyperplastic polyps called serrated adenomas. Ordinary hyperplastic polyps do not develop into cancer.

Risk Factors

  • Environment and life-style - High fat intake, fried foods, frequent use of tobacco and alcohol, obesity and inactivity are probably associated with increased incidence of colorectal cancer.
  • Inflammatory bowel disease (ulcerative colitis/Chrohn’s disease) increases the risk of colorectal cancer.
  • Previous irradiation.

Histology of colon and rectum cancer

Around 98% of all cancers in the colon and rectum are adenocarsinomas. The others are spinocellular carsinomas, carsinoids, lymphomas and sarcomas.

The intestinal wall includess three layers:

  • Mucosa (three layers)
  • Submucosa (may be divided into three levels of depth)
  • Muscularis propria (the muscle layer)

Cancer in the colon and rectum generally originate from epithelial cells in the mucosa and starts as a polyp (adenoma) with irregular cell. When the cell division is no longer under control and the cells obtain  properties that enable them to infiltrate the surrounding tissues a cancer has developed. A diagnosis of cancer is possible when atypical cells have infiltrated the submucosa.

Precursor lesions

Precursor lesions are benign intramucosal neoplasias often appearing as polyps or adenomas. Adenomas are divided into tubular villous and tubulo-villous adenomas according to the presence of glands (tubules), villous structures or a combination of both. In addition the adenomas are classified according to the degree of cellular atypia and changes in morphology.

  • Low grade intraepithelial neoplasia – previously called slight or moderate dysplasia
  • High grade intraepithelial neoplasia – previously called grov dysplasia
  • Intramucosal neoplasia – prevoiously called intramucosal carcinoma: the changes are found in lamina propria, but not through the muscularis mucosa and is not manifest cancer

Serrated adenoma is a special variant of hyperplastic polyps and can develop into cancer.

    Adenocarcinomas

    Adenocarcinomas produce abnormal glands that infiltrate the submucosa and further through the muscle layer and into the surrounding tissues (extramurally). In the submucosa, the tumor can infiltrate lymphatic vessels and thus spread to lymph nodes or infiltrate veins and develop metastasis in the liver or other organs.
     

    Photomicrograph with adenocarcinoma infiltrating the submucosa. Click to enlarge. Photomicrograph with adenocarcinoma infiltrating the muscularis mucosa. Click to enlarge. Photomicrograph with adenocarcinoma infiltrating perirectal  tissue. Click to enlarge.

    Adenocarcinomas are graded according to deviation from normal glandular tissue (differential grade). About 20% of the tumors are poorly differentiated and have a worse prognosis than the well to moderately differentiated which compose the other  80%.

    Mucinous adenocarcinoma 

    Mucinous adenocarcinomas are the second most common type of cancer (about 5%) and are diagnosed when mucus occurs in  > 50 % of the tumor tissue. These have a worse prognosis than non-mucinous carsinomas.
     

    Photomicrograph of a primary mucinous adenocarcinoma. Click to enlarge.

    Other cancer types

    The following variants are infrequent: Signet ring-cell carcinoma, Small cell carcinoma, Squamous cell carcinoma, Adenosquamous carcinoma, Medullary carcinoma, Undifferentiated carcinoma.

    Other types of cancer can also appear in colon and rectum, although they are more common in other parts of the gastrointestinal tract: Lymphoma, Endocrine tumors and Sarcomas (Gastrointestinal stromal tumor -GIST).

    Staging of colon and rectum cancer

    The extension of the cancer (stage) is classified according to the TNM- (UICC/AJCC) system.

    The cancer stage at the time of diagnosis

    The size and depth penetration of the tumor is (T), regional lymph node metastases (N), and/or distant metastases (M). Based on TNM four stages are constructed. The TNM system is frequently revised: TNM 5.ed. 1997, TNM 6.ed. 2002, TNM 7. ed 2010. The number of the applied version should always be given as the criterias varies between the versions.

    Tumor depth penetration (T)

    • Carcinoma in situ
      • High grade intraepithelial neoplasia, previously called high grade dysplasia.
      • Intramucosal neoplasia (infiltration onto, but not through the lamina propria and muscularis mucosa).
    • T1:  Infiltration of submucosa
      • Flat T1 tumors is sub classifies according to Kudo/Kikuchi in three groups.
        • sm1-3 according to the penetration depth into submucosa. This is of practical importance when a local excision is considered.
      • T1 in pedunculated polyps are classified according to Haggit. This is of practical importance for the evaluation of the radicality of a sling resection .
    • T2:  Infiltration of muscularis propria.
    • T3:  Infiltration through the intestinal wall into subserosa /pericolic (rectal).
    • T4a: Infiltration into and through the visceral peritoneum (TNM 7.ed 2010).
    • T4b: Infiltration into surounding organs (TNM 7.ed 2010). T4a/b was the other way around in previous version.

    T1

    T2-3

    T4

    Lymph node status (N)

    • N0: No presence of metastatic lymph nodes
    • N1a: 1 metastatic lymph node
    • N1b: 2-3 positive lymph nodes
    • N1c: Small deposits of tumor in pericolic /rectal tissue not apparently in or developed in lymph node
    • N2a: 4-6 positive lymph nodes
    • N2b: 7 or more positive lymph nodes 

    Distant metastases (M)

    • M0: No distant metastases
    • M1: Distant metastases present

    The stage of the cancer - TNM classification

    The extension (stage) of the cancer should be assessed before start of the treatment. This is called clinical stage cTNM. cTNM is based on cT (clinically evaluated T), cN (clinically evaluated lymph node), cM (clinically evaluated distant metastases). TNM stage is also commonly named by separate examination, for instance MR based = mT, mN.

    cTNM is based on all available information from:

    • Clinical examination
    • Endoscopy
    • Radiology

    The final stage is given after the evaluation of the pathology specimen, and is given prefix “p”. Pathological TNM (pTNM) is based on pT, pN and the apprehension of M (operation/ radiology).

    If the patient has received neoadjuvant treatment, this may have changed the size and grade of infiltration of the tumor and also extent of lymph node metastases. The pathology TNM can therefore vary from the cTNM before the treatment started. Pathology stage after neoadjuvant treatment shall therefore be given as yTNM. yTNM, pathology stage after neoadjuvant treatment is based on yT and yN.

    The final stage is based on pT, pN and M. In ordinary routine only 5 stages are applied. The table below shows the TNM (UICC/AJCC) and Dukes' stages.

    TNM (UICC/AJCC) stages and Dukes' stages

    UICC-stage T N M Dukes
    0 Tis N0 M0 0
    I T1, T2 N0 M0 A
    II
    T3, T4
    N0 M0 B
    III
    Any T
    N1-2 M0 C
    IV Any T Any N M1 D

    Stratification according to these 5 categories achieves inaccurate prognostic groups. For better comparable groups staging into 10 subgroups is available.

    TNM (UICC/AJCC) stages and Dukes' stages

    UICC-stages T N M Dukes
    0 Tis N0 M0 0
    I T1, T2 N0 M0 A
    II A T3 N0 M0 B
    II B T4a N0 M0 B
    II C
    T4b N0 M0 B
    III A

    T1-T2

    T1, T2

    N1

    N2a

    M0

    M0

    C
    III B

    T3, T4a

    T2, T3

    T1, T2

    N1

    N2a

    N2b

    M

    M0

    M0

    C
    III C

    T4a

    T2, T4a

    T4b

    N2a

    N2b

    N1, N2

    M0 C
    IV A
    Any T Any N
    M1a D
    IV B
    Any T
    Any N
    M1b D

    Classification according to oncological treatment effect

    The treatment effect after chemoradiation is evaluated by Tumor Regression Grading (TRG), which involves assessment of the relative amount of tumor cells and desmoplastic reaction (fibrosis). Classification systems applies 3- or 5- subgroups.

    Example of 5-part TRG-graded surgical specimens (19) (click to enlarge images)

    Grade 1

    Complete tumor regression. No tumor cells evident, only fibrosis.

    Grade 2

    Tumor cells spread in fibrosis.

    Grade 3

    Increased number of tumor cells, but still fibrosis dominating the image.

    Grade 4

    Tumor cells dominating.
    Little fibrosis.

    Grade 5

    Well maintained tumor tissue. No fibrosis.

     

    Classification of residual tumor (R-stage)

    This classification is based on x-ray examination before/ during the operation, the surgical peroperative findings and the pathology examination of the resected specimen.

    • R0 – No known distant metastases, no local remaining tumor identified by the surgeon preoperatively, no microscopic tumor remains after surgery.
    • R1 – Microscopic tumor in the resection margin of within 1 mm from this (=circumpherential resection margin < 1 mm) and no further known remaining tumor.
    • R2 – Macroscopic tumor remains locally (identified by the surgeon) or distant metastases not resected.

    Metastatic patterns of colon and rectum cancer

    Local extension in the gut wall

    A local cancer can expand locally into the gut wall and along it. The latter can be both circumpherentially and longitudinally. Tumor nests may be found in the gut wall as far as 1 cm from the macroscopic tumor.

    Local extension in the pericolic/-rectal fat

    In contrast to the extension in the bowel wall, microscopic tumor may be found in the pericoloc/ perirectal fat up to 5 cm from the macroscopic margin of the tumor. This may be located within the fat itself or within lymph nodes, and may be found both orally and anally to the tumor. It is therefore recommended to resect at least 10 cm of colon and pericolic fat away from the cancer and at least 5 cm in the rectum.

    Direct invasion of neighboring organs

    Cancer in the colon can directly invade the urinary bladder, small bowel, duodenum, the internal genitals, the abdominal wall, retroperitoneum and seldom other organs.

    When the cancer is located in the intraperitoneal part of the gut it can grow through the peritoneum and give rise to intraperitoneal seeding of tumor cells and peritoneal carsinomatosis. This is present in around 8% of colon cancer at operation, more seldom in rectal cancer.

    Cancer in the rectum can cause:

    • Infiltration in the pelvic wall, ureter, large pelvic vessels-and nerves
    • Infiltration into vagina, uterus, prostate, seminal vesicles, prostate, urinary bladder

    Lymphogenic metastases

    Lymphatic vessels are located in the submucosa and deeper parts of the gut wall. During infiltration of the superficial part of the submucosa, lymphogenic spreading is very infrequent (< 5%). During infiltration of the deeper parts of the submucosa and the muscularis propria lymphogenic spreading appears in 15-20%, and even more frequent when infiltrating the pericolic fat. Metastases appear in local lymph nodes 15-20% of all operated for colorectal. Among all patients operated for intestinal cancer 35-40% have metastases to the regional lymph nodes.

    The regional lymph nodes are divided into different locations:

    • Epiploic (close to the gut), N1 ( Japanese classification)
    • Intermediate, N2
    • Central- apical, N3

    This division is the basis for the D1-, D2-, D3- dissections.

    The tumor can further spread along the lymph nodes at the aorta, in the liver ligament, mediastinum and supraclavicularly. From rectal cancer the tumor can spread to mesorectum and along the inferior mesenteric vessels (regional metastases). Metastases can also appear in the lymph nodes of the pelvic wall, and very seldom (low cancer/ obstruction of oral lymph flow) to the inguinal lymph nodes (distant metastases).

    Hematogenic spreading

    Colo-rectal cancer can infiltrate into extramural vessels and from here migrate through the blood stream out of the loco-regional area and develop distant metastases. These will primarily appear in the liver (15-20% at the time of diagnosis), lungs (5%), and more seldom to the skeleton, brain and kidneys.

    Microscopic accumulations of tumor cells can often be found in the bone marrow without development of clinical metastases.

    Symptoms of colon and rectum cancer

    • Blood in the stools. This is always an alarming symptom and must be immediately examined.
      • Fresh red, externally on the feces (low source of the bleeding)
      • Darker red mixed with the stools (source of bleeding in the colon)
      • Occult (often from the oral part of the colon)
    • Bleeding anaemia
    • Change of bowel habits. Changing constipation/ loose stools is frequent in cancer of colon. In 15-20% complete obstruction is due to narrowing of the bowel lumen. In rectal cancer frequent, loose stools and imperative defecation is typical for cancer of a certain size.
    • Pains, often colicy with exacerbation after meal is often seen when the bowel lumen is much reduced. This is most frequently seen in cancers located close to the small/large bowel transition zone.
    • Palpable tumor in the abdomen may be identified in slim patients.
    • Weight reduction, reduced general condition can be seen in advanced cases, especially in metastatic disease.


    Differential diagnoses of colon and rectum cancer

    • Other cancer in the gut (anaemia)
    • Hemorrhoids, inflammatory bowel disease, radiation enteritis (bleeding)
    • Irritable bowel syndrome (IBS), food intolerance, coeliaci, inflammatory bowel disease (diarhoea)
    • IBS, diverticulosis (changing bowel habits)

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    Prognosis of colon and rectum cancer

    The prognosis depends on whether the colon and rectum cancer is localized, regional, or metastatic at the time of diagnosis. 39.2% are diagnosed at the local stage and the 5-year survival for localized colon and rectum cancer is 89.9%. The overall 5-year survival rate for colon and rectum cancer patients during the period 2007-2013 was 64.9%.

    Colon and rectum cancer is the second leading cause of cancer death in the United States. The number of  deaths is highest among people aged 75-84. Death rates have been falling on average 2.7% each year over 2004-2013.

    In 2014, there were an estimated 1,317,247 people living with colon and rectum cancer in the United States and in 2017 there are an estimated 50,260 people will die of this disease. (18)

     

     

      

    References on colon and rectum cancer

    1. Heald RJ. The 'holy plane' of rectal surgery. J R Soc Med 1988; 81(9):503-8.
    2. Wibe A, Møller B, Norstein J, Carlsen E, Wiig JN, Heald RJ et al. A national strategic change in treatment policy for rectal cancer--implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis Colon Rectum 2002; 45(7):857-66.
    3. Wong CS, Cummings BJ, Brierley JD, Catton CN, McLean M, Catton P et al. Treatment of locally recurrent rectal carcinoma--results and prognostic factors. Int J Radiat Oncol Biol Phys 1998; 40(2):427-35.
    4. Brændengen M, Tveit KM, Hjermstad MJ, Johansson H, Berglund K, Brandberg Y, Glimelius B.Health-related quality of life (HRQoL) after multimodal treatment for primarily non-resectable rectal cancer. Long-term results from a phase III study.Eur J Cancer. 2012 April 48;6: 813-9. PMID: 21782418
    5. Folkesson J, Birgisson H, Påhlman L, Cedermark B, Glimelius B, Gunnarsson U. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol 2005; 23(24):5644-50.
    6. Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T et al. The TME Trial After a Median Follow-up of 6 Years: Increased Local Control But No Survival Benefit in Irradiated Patients With Resectable Rectal Carcinoma. Ann Surg 2007; 246(5):693-701.
    7. Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345(9):638-46.
    8. Habr-Gama A, Perez RO, Nadalin W, Nahas S, Ribeiro U, e Sousa AS et al. Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival. J Gastrointest Surg 2005; 9(1):90-9.
    9. Wiig JN, Poulsen JP, Larsen S, Brændengen M, Wæhre H, Giercksky K-E. Total pelvic exenteration with preoperative irradiation for advanced primary and recurrent rectal cancer. Eur J Surg 2002; 168(1):42-8.
    10. Law WL, Chu KW, Choi HK. Total pelvic exenteration for locally advanced rectal cancer. J Am Coll Surg 2000; 190(1):78-83.
    11. Wiig JN, Larsen S, Dueland S, Giercksky K-E. Preoperative irradiation and surgery for local recurrence of rectal and rectosigmoid cancer. Prognostic factors with regard to survival and further local recurrence. Colorectal Dis 2007; Accepted.
    12. Hahnloser D, Nelson H, Gunderson LL, Hassan I, Haddock MG, O`Connell et al. Curative potential of multimodality therapy for locally recurrent rectal cancer. Ann Surg 2003; 237(4):502-8.
    13. Huebner RH, Park KC, Shepherd JE, Schwimmer J, Czernin J, Phelps ME et al. A meta-analysis of the literature for whole-body FDG PET detection of recurrent colorectal cancer. J Nucl Med 2000; 41(7):1177-89.
    14. Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 2005; 6(7):477-84.
    15. Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AHM et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 2007; 25(21):3061-8.
    16. Kaminski MF, Regula J. Colorectal cancer screening by colonoscopy--current issues. Digestion 2007; 76(1):20-5.
    17. Wiig JN, Berner A, Tveit KM, Giercksky KE. Evaluation of digitally guided fine needle aspiration cytology versus fine needle core biopsy for the diagnosis of recurrent rectal cancer. Int J Colorect Dis 1996; 11:272-5.
    18. Howlader N, Noone AM, Krapcho M, Miller D, Bishop K, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2014, National Cancer Institute. Bethesda, MD
    19. Bouzourene H, Bosman FT, Seelentag W, Matter M, Coucke P. Importance of tumor regression assessment in predicting the outcome in patients with locally advanced rectal carcinoma who are treated with preoperative radiotherapy. Cancer. 220. 1994; 15(4):1121–30
    20. Bruheim K, Guren MG, Skovlund E, Hjermstad MJ, Dahl O, Frykholm G, Carlsen E, Tveit KM.Late side effects and quality of life after radiotherapy for rectal cancer.Int J Radiat Oncol Biol Phys. 2010 Mar 15;76(4):1005-11. Epub 2009 Jun 18. PMID: 19540058
    21. Nasjonalt handlingsprogram med retningslinjer for diagnostikk, behandling og oppfølging av pasienter med kreft i tykk og endetarm (2015), Helsedirektoratet (National guidelines for diagnostic, treatment and follow-up care of colon and rectum cancer, Norwegian Directorate of Health)

     

         References on the surgical partA. Nesbakken

    • Improving outcomes in colorectal cancers: research evidence for the manual update. London: National Institute for Clinical Excellence; 2004.
    • Nationella riktlinjer för kolorektalcancersjukvård: medicinskt och hälsoekonomiskt faktadokument. Stockholm: Socialstyrelsen; 2007. Tilgjengelig fra: http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/8944/2007-102-3_20071024.pdf
    • NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)Fort Washington, PA: National Comprehensive Cancer Network [oppdatert 2009; lest 2009]. Tilgjengelig fra: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (krever registrering)
    • Otchy D, Hyman NH, Simmang C, Anthony T, Buie WD, Cataldo P, et al. Practice parameters for colon cancer. Dis Colon Rectum 2004;47(8):1269–84.
    • Hohenberger W, Reingruber B, Merkel S. Surgery for colon cancer. Scand J Surg 2003;92(1):45–52.
    • Kim JC, Lee KH, Yu CS, Kim HC, Kim JR, Chang HM, et al. The clinicopathological significance of inferior mesenteric lymph node metastasis in colorectal cancer. Eur J Surg Oncol 2004;30(3):271–9.
    • Berger AC, Sigurdson ER, LeVoyer T, Hanlon A, Mayer RJ, Macdonald JS, et al. Colon cancer survival is associated with decreasing ratio of metastatic to examined lymph nodes. J Clin Oncol 2005;23(34):8706–12.
    • Kelder W, Inberg B, Schaapveld M, Karrenbeld A, Grond J, Wiggers T, et al. Impact of the number of histologically examined lymph nodes on prognosis in colon cancer: a population-based study in the Netherlands. Dis Colon Rectum 2009;52(2):260–7.
    • Le Voyer TE, Sigurdson ER, Hanlon AL, Mayer RJ, Macdonald JS, Catalano PJ, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21(15):2912–9. 134
    • Rosenberg R, Friederichs J, Schuster T, Gertler R, Maak M, Becker K, et al. Prognosis of patients with colorectal cancer is associated with lymph node ratio: a single-center analysis of 3,026 patients over a 25-year time period. Ann Surg 2008;248(6):968–78.
    • Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome. Colorectal Dis 2009;11(4):354–64.
    • Smith AJ, Driman DK, Spithoff K, Hunter A, McLeod RS, Simunovic M, et al. Guideline for optimization of colorectal cancer surgery and pathology. J Surg Oncol 2010;101(5):12.
    • West NP, Morris EJ, Rotimi O, Cairns A, Finan PJ, Quirke P. Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 2008;9(9):857–65.
    • West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P. Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 2010;28(2):272–8.
    • Croner RS, Merkel S, Papadopoulos T, Schellerer V, Hohenberger W, Goehl J. Multivisceral resection for colon carcinoma. Dis Colon Rectum 2009;52(8):1381–6.
    • Hunter JA, Ryan JA, Jr., Schultz P. En bloc resection of colon cancer adherent to other organs. Am J Surg 1987;154(1):67–71.
    • Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365(9472):1718–26.
    • Hazebroek EJ. COLOR: a randomized clinical trial comparing laparoscopic and open resection for colon cancer. Surg Endosc 2002;16(6):949–53.
    • Kuhry E, Bonjer HJ, Haglind E, Hop WC, Veldkamp R, Cuesta MA, et al. Impact of hospital case volume on short-term outcome after laparoscopic operation for colonic cancer. Surg Endosc 2005;19(5):687–92.
    • Kuhry E, Schwenk WF, Gaupset R, Romild U, Bonjer HJ. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database Syst Rev 2008;(2):CD003432

    Diagnostics of cancer in the colon and rectum

    The purpose of the diagnostic tests is to assess whether cancer is present and to identify the stage of the disease.

    Diagnostic examinations

    Clinical examination

    The clinical examination should include a thorough history of the disease and abdominal and rectal palpation. Recently appearing symptoms must be examined without delay. A considerable “doctor’s delay” may be due to the lack of these clinical examinations.

    Laboratory testing

    • CEA (carsino-embryonal antigen) is used to identify advanced stage (CEA above 50 strongly indicates metastatic stage). It is also used to monitor recurrence after supposed curative operation. CEA is only elevated in 50% of the patients with cancer in the colon-rectum, and can therefore not be used as a screening test.
    • Examinations for occult blood in the feces are applied for alarming symptoms without simultaneous macroscopic blood in feces. There are two main kinds of such tests. One is based on guiac testing (FOBT), the other is an immunologic test (FIT). Both tests are fairly sensitive, but not very specific.
    • Liver test are performed for identified liver metastases

    Proctoscopy with biopsy

    When there is a suspicion of cancer located in the lower part of the gut the rectum should always be examined, either with a rigid sigmoidoscope or a flexible colonoscope. With the rigid sigmoidoscpope an experienced examiner can visualize the lower 20-25 cm of the gut. Small lesions located in the lower part, especially dorsally, may easily be missed by examination can be rather painful when a cancer is present and a flexible scope may be more lenient and provide a more thorough examination.

    Rigid sigmoidoscopy should always be performed as this will more accurately identify the level of the tumor from the anal verge.

    Flexible endoscopy is the primary choice when cancer of the colon is suspected. All patients with a cancer should have a total colonoscopy preoperatively to identify synchronous polyps or cancers. If the tumor lumen cannot be penetrated a total colonoscopy should be performed within 3 months postoperatively. Preoperative CT-colography can be performed in such cases.

    Biopsy

    All tumors are biopsied during endoscopy. Not infrequently forceps-biopsy will underestimate the stage. Polyps with low grade dysplasia may in about 30% contain high grade dysplasia. In case of cancer the biopsy will show only dysplasia in up to 40% of cases. The macroscopic appearance is therefore important. In case of definite cancer by endoscopy, a benign biopsy cannot be considered of definite importance and re-biopsy should be performed.

    CT colegraphy/ Virtual coloscopy

    The examination is performed with CT double contrast and provides a 2- or  3-dimensional image of the bowel lumen. Polyps  and tumors above 1 cm are nearly always identified.

    Examinations for loco-regional staging

    For a trained endoscopist the macroscopic appearance will give a good indication whether a T1, T2, or a T3 cancer is present, still additional imaging is important.

    CT abdomen

    CT of the abdomen is applied for the staging of cancer of the colon. It acceptably differentiates between T1-2 and T3 cancers  (whether there is penetration of the bowel wall.). It can also identify infiltration into neighbouring organs, and whether there are enlarged (or irregular) lymph nodes as sign of stage III disease.The specificity for lymph node metastases is unfortunately low. Additionally the anatomy of the mesocolic vessels can be described which may be of help to the surgeon.

    MRI rectum/ pelvis

    MRI of the rectum/ pelvis is the examination of choice for T3 and T4 cancer in the rectum. The examination is less accurate regarding T1 and T2 cancers which are often overstaged. Similarly ,benign broad based polyps will often be staged as infiltrating cancer (most often considered mrT2). MRI as the sole indication of cancer should therefore never be trusted. MRI is also the best examination for lymph node metastases in the mesorectum, along the pelvic wall and the inguinal region. The specificity is not very high and only lymph nodes which an experienced MRI radiologist consider definite metastases should be taken into account. MRI is also the method of choice for the estimation of the distance from tumor or mesorectal lymph node metastases to the mesorectal fascie. A distance of 2mm or less is indication for neoadjuvant treatment in patient who can tolerate such treatment. In locally advanced cancer the MRI can identify to the surgeon if and how an extended TME can be performed. The MRI examination must be performed in a standardized way and it requires great dedication and skill to interpret the images.

    Transrectal ultrasound

    This is the best examination for rectal cancer at an early stage (T1-TY2) and should be mandatory before local excision of rectal cancer. It is the technique of choice for the sm- staging. It is also possibly the best technique for identifying infiltration into the prostate. Unfortunately few doctors in Norway are skilled in this technique.

    Examinations for evaluation of distant spread.

    • CT of the lungs is mandatory for the evaluation of lung metastases. Uncharacteristic lesions of up to 6 mm should not be considered during evaluation of primary treatment.
    • CT of the abdomen is always performed to identify liver metastases or peritoneal carsinomatosis. In some rare cases lymph node metastases central to the regional area, metastases in adrenal glands or other areas may be identified.
    • MRI of the liver is applied to verify suspected metastases. Performed according to a specific protocol this is more sensitive and specific than CT of the liver.
    • Contrast enhanced ultrasound (CEUS) of the liver is sometimes performed to differentiate between small cysts and metastases.
    • PET-CT is seldom indicated at the time of diagnosis. It can give additional information on distant metastases in rare localisations. PET-CT is not considered better than CT for evaluation of lung/ liver spreading, but may be appropriate in cases of recurrence after previous treatment.

    PROSEDYRER

    Ano-/rectoscopy

    General

    Ano- /rectoscopy is done when:

    • proven blood (visible or occult) or other symptoms suggestive of cancer in the rectum.
    • postoperative control after earlier bowel cancer operation.

    Purpose

    • Uncover polyps or infiltrating cancer in the rectum.
    • Consider tumors exact location of the rectum, which is important in preparing the type of operation.
    • Consider the exact location of the tumor , which is important in preparing the type of operation.

    Equipment

    • Rectoscope, possibly anoscope
    • Suction
    • Biopsy forceps
    • Swabs on pole


    Preparation

    • Fasting or change of diet is not necessary.
    • The colon is emptied the day of the examination with enema, possibly with two Toilax® tablets the day before and enema directly prior.
    • If the patient uses anticoagulants and it is necessary to take biopsies or slinging polyps (usually), the patients should consult their doctor to ensure the safety of taking a break in the medication according to the following rules:
      • Plavix® and equivalent antiplatelet is not to be discontinued if they have been in use < 1 year, otherwise stop may be considered.
      • Pradaxa®, Xarelto® and Eliquis® must be stopped two days before the examination, earlier if renal impairment.
      • Restarted after two days if a sling resection or another examination that can cause bleeding is performed.
      • Marevan® (warfarin) is stopped five days before the examination. INR is measured an hour before the procedure and should be below 1,8. If the patient has a high risk of thrombosis (heart valve and others) low molecular weight heparin must be considered. Start with double dose of Marevan® (warfarin) the same evening.
      • Albyl-E® (Acetylsalicylic Acid) can be continued.
      • Any other medications in the morning can be taken as usual.

    If it is contraindicated to discontinuate (for example dual antiplatelet agent), and there is an indication to perform the examination as soon as possible, a tailored program should be made in collaboration with the general practitioner and possibly a cardiologist/haematologist.

    Implementation

    • The anal canal is lubricated and palpated with a finger to ensure that the canal is open.
    • A 25 cm long rigid scope with a diameter of approximately 2cm is inserted through the analcanal with oburator in place. Blind insertion approximately 4cm, direction towards umbilicus.
    • Obturator is retrieved and further insertion is performed by using the eyes. First in the direction of 90 degrees backwards relative to the anal canal, then gradually more forward, follows the curve of rectum. A trained examiner can usually insert the scope  into  sigmoidum in a level 25 cm above the anal opening.
    • Air is inflated into the bowel for dilation, the scope is retrieved and a full inspection is performed.
    • Any polyps/tumors are identified and described in the best possible way
      • size/spread
      • Exact location (level above anal opening and spread around circumferences).
    • Biopsies are taken by neoplasms or inflammations.

    Follow-up

    The patient can leave the hospital immediately and start with regular medications the same day.

    Examining physician follows up test results and informs the patient of any further investigation and control.

    Colonoscopy

    General

    Colonoscopy is performed when:

    • proven blood (visible or occult), or other symptoms suggestive of colorectal cancer.
    • screening of asymptomatic patients with known hereditary risk of colorectal cancer.
    • postoperative control after colon cancer surgery.
    • control in inflammatory bowel disease (IBD).

    Purpose

    • Uncover polyps or infiltrating cancer of the colon and rectum.
    • Postoperative control of the anastomosis areas concidering recurrence of cancer or stricture formation.
    • Postoperative control to check whether new polyps or cancer (metachronous) has occurred.
    • Assessing disease activity and any development of dysplasia by IBD.

    Equipment

    • Coloscope with associated equipment
    • Biopsy forceps
    • Sling for removal of polyps

    Preparation

    • Fasting is not necessary. High-fiber bread, cereals, linseed or fruits/vegetables with a lot of seeds should be avoided the last five days before the examination.
    • Patients should avoid iron supplements in the last seven days before the examintaion.
    • Bowel emptying through taking oral laxative solutions (an abundant bowel emptying is necessary).
    • If the patient uses anticoagulants and it is necessary to take biopsies or slinging polyps (usually), the patients should consult their doctor to ensure the safety of taking a break in the medication according to the following rules:
      • Plavix® and equivalent antiplatelet is not to be discontinued if they have been in use < 1 year, otherwise stop may be considered.
      • Pradaxa®, Xarelto® and Eliquis® must be stopped two days before the examination, earlier if renal impairment.
      • Restarted after two days if a sling resection or another examination that can cause bleeding is performed.
      • Marevan® (warfarin) is stopped five days before the examination. INR is measured an hour before the procedure and should be below 1,8. If the patient has a high risk of thrombosis (heart valve and others) low molecular weight heparin must be considered. Start with double dose of Marevan® (warfarin) the same evening.
      • Albyl-E® (Acetylsalicylic Acid) can be continued.

    If it is contraindicated to discontinuate (for example dual antiplatelet agent), and there is an indication to perform the examination as soon as possible, a tailored program should be made in collaboration with the general practitioner and possibly a cardiologist/haematologist.

    • Any other medications in the morning can be taken as usual.
    • If the patient has diabetes and use insulin, an appointment early in the day can be made.
    • The bladder should be empty before the examination.

    Implementation

    • Before total colonoscopy premedication with intravenous analgesics and possibly sedation are usually administered.
    • The patient is located in a left lateral position.
    • The anal canal is lubricated and palpated with a finger to ensure that the canal is open.
    • The coloscope is being inserted and it is attempted to use as little air as possible during insertion to minimize discomfort.
    • As the scope is inserted upwards the patient turns into a supine position, possibly another position.
    • If there is difficulties during the insertion the assistant will "stabilize" the intestine by holding his hands on the patient´s stomach.
    • If the patient experiences the examination as painful, more medications are administered.
    • The scope is rapidly, but gently inserted to the cecum, possibly into the terminal ileum. Then more air is filled in and the scope is slowly pulled down while all parts of the intestine are being visualized.
    • Any lesions are being biopsied, or possibly removed.

    The examination lasts for about 15 - 60 minutes.

    Follow-up

    • The patient can eat and drink immediately after the procedure, unless otherwise indicated.
    • The patient can usually go home quite immediately. If he/she is tired after the examination/medications, or a procedure that leads to increasing risk for complications is performed, the patient may be in the hospital for observation in one to three hours before going home.
    • The patient is informed about possible complications:
      • Bleeding from the rectum if polyps are removed.
      • Abdominal pain which do not disappear quickly after a completed examination, may lead to suspicion of bowel perforation. This may occasionally occur during diagnostic colonoscopy, while it is more common after biopsy/sling resection.

    The physician in charge of the examination is following up test results and informs the patient about any further investigation and control.

    Treatment of cancer in the colon and rectum

    After the preoperative evaluation of the disease stage, age of patient and expected remaining life span, general condition and comorbidity one of the following conditions are present:

    • Expected curative situation – Curative treatment is started.
    • Uncertain, potential curative situation – Curative treatment is started
    • Definite uncurable situation – Best palliative treatment is started
    • Independent of stage of the disease
      • Fragile patient- Compromise – Customize treatment
      • Very fragile patient – Only best supportive care

    When curative treatment is intended all macro and microscopic tumor tissue must be surgically resected -R0 resection (R= residual tumor). There must be locoregionally free margins around the tumour and mesorectum and possible metastatic lymph nodes must be excised.

    Curative treatment

    Cancer at a very early stage

    T1 sm1- (possibly also sm2) in the rectum may be locally resected. This should be performed by transanal endoscopic microsurgery (TEM) by a well skilled surgeon.

    T1 tumor on top of pedunculated polyps may be resected by snare, both in the colon and rectum.

    Localized cancer (T1–T3 with or without lymph node metastases)

    Cancer in the colon must be resected with removal of the tumor and 10 cm of the gut in each direction including the mesocolon and regional as well as central lymph nodes. Preoperative (neoadjuvant) treatment is unnecessary.

    Stage III and high risk stage II patients shall have adjuvant chemotherapy for 6 months when the patient’s general condition can tolerate this.

    Cancer of the upper and middle rectum require low anterior resection performed as total mesorectal excision (TME) according to Heald, with colorectal/-anal anastomosis or in some cases Hartmann’s procedure without anastomosis. When the distance from tumor of lymph node metastases to the mesorectal fascia is >2 mm no preoperative treatment is necessary while preoperative treatment should be givent for distances ≤ 2 mm.

    Cancer in the lower rectum is ordinarily operated by rectal amputation (abdomino perineal resection - APR) with permanent end-sigmoidostomy. This should be performed as a cylindrical resection when the tumor threatens the margin of a standard APR.

    Locally advanced cancer

    T4 cancer of the colon, infiltrating neighbouring organs, is defined as locally advanced. Neoadjuvant treatment is not routine in Norway for such cases. The dissection must be performed outside the mesocolic plane when the tumor infiltrates through this, and adjacent involved organs must be totally or partly resected to obtain tumorfree margins. The area at risk of the resection margin, or where macroscopic tumor remains should be marked with clips for the identification at postoperative imaging and possible radiotherapy.

    In the rectum T4 and T3 tumors closer than 2 mm from the mesorectal fascia are defined as locally advanced. Such patients are candidates for neoadjuvant treatment. Thereafter standard TME resection may be performed when this results in a R0 resection. If not, an extended TME must be performed. The tumor stage before the adjuvant treatment determines whether a standard or extended TME should be performed.


     

    Surgery of colon cancer

    Curative resections can be performed by laparotomy or laparoscopy. Large studies have shown that both techniques are equivalent with regard to oncological result and complications. Regardless of operative approach the same surgical principles applies. Adequate resections implies removal of the tumor containing bowel segment, regional mesentery with lymph nodes, dissection in the correct plane around bowel and mesentery , with technique which will secure R0-resection.

    Lymph node dissection

    The regional lymph nodes are classified in three groups according to the localization: Bowel near (N1), intermediary (N2) and central (N3). The similar terminology to describe the extension of the lymph node dissection is D1-, D2- and D3- dissection (“high tie”).

    For all curative resections a complete D2-resection should be performed as a minimum. There is no definite proof that D3- dissection will secure better result than D2-dissection, but there are several good reasons suggesting that D3- dissection should be the gold standard:

    • 2-4% of all patients have central lymph node metastases without simultaneous distant metastases. These patients can be potentially cured by a D3-dissection but will have regional recurrence after D2-dissection.
    • Several studies show that a higher number of examined lymph nodes in the specimen results in a better prognosis. Even though this may be due to various reasons, it probably also suggests that an extensive lymph node dissection is beneficial.
    • Centers performing D3-dissections as a standard report good results.

    Bowel resection

    It has been customary to resect the tumor containing bowel segment including 10 cm free margin orally and anally. However, 5 cm is also considered adequate in the large bowel. From an oncological point of view we   therefore recommend 10 cm free margin on the bowel and the pericolic lymph nodes in all segments of the large bowel except at the rectosigmoid flexure where 5 cm is adequate anally. The extent of the resection will in addition be decided from the anatomy of the vessels and the circulatory conditions of the bowel after the lymph node dissection and central vascular ligation has been performed.

    Dissection around the primary cancer in the pericolic plane:

    As in the rectum, where there is a defined plane (often called “the holy plane”) on the outside of the mesorectal fascia, there is a defined retroperitoneal plane in all segments of the colon. This plane is in between the back of the visceral mesocolon and the parietal part of the peritoneum. By careful dissection this plane may be followed around the whole extent of the colon. When the bowel has been mobilized the mesocolon will be intact and include colon containing the primary tumor, all lymph vessels, lymph nodes and blood vessels.

    The anterior part of this “package” is covered by peritoneum, the dorsal aspect by a mesocolic “fascia”. If this “package” is traumatized or dissected into the possibility of spread or leaving behind viable cancer cells similar to the rectal procedure. Dissection in the correct plane is important in the circumference around the primary tumor and in the central parts of the mesentery.

    A study for Leeds in England has shown that the “mesocolic plane” is damaged in more than half of the specimens after “standard” resection. Cases with intact mesocolic fascia had better prognosis than patients where this was injured and the dissection had entered the outer part of the bowel wall.

    Hohenberger (Erlangen) has systematized and described the dissection around the primary tumor and the adjoining mesentery and has introduced the  notion “complete mesocolic excision”. He will always combine this with D3-dissection of lymph nodes and has reported excellent results. In a comparative study a far higher percentage of intact “oncological package” was found after operation in Erlangen than in Leeds (92% vs 40%).

    When the tumor infiltrates adjacent organs an en-bloc resection should be performed with resection of the relevant organ(s) avoiding contact with tumor tissue. An en-bloc R0-resection can have nearly identical prognosis as for tumors not involving neighbouring organs. Dissection into tumor will dramatically reduce the prognosis. Biopsy should be performed in case remaining tumor is considered. Areas with unresectable tumor should be marked with metal clips for identification of the area in case of later irradiation.

    Iatrogenic perforation of the bowel close to tumor is extremely rare in cases of colon cancer. More commonly the tumor perforates preoperatively. This will entail a worse prognosis and such patients should therefore be considered for adjuvant oncological treatment.

    Surgical treatment has two phases:

    • Resection of the tumor. In this phase, the least amount of manipulation of the tumor as possible is done before all veins draining the tumor are ligated to reduce spreading of liberated cancer cells by circulation.
    • Reconstruction of function and closing of abdominal wall/peritoneum.

    There is a direct correlation between surgical technique and prognosis for rectal cancer. This is not to the same extent for colon cancer.

    There is also a clear correlation between acute surgery and postoperative complications. Acute cancer surgery should therefore be avoided when possible.

    Early stage cancer

    Treatment of T1 tumor in pedunculated polyp

    • T1 tumors in pedunculated polyps, Haggitt level 1 and 2, are curatively removed by endoscopic loop resection when there is a microscopic free resection margin.
    • With Haggitt level 3, the resection margin will often be uncertain. In the rectum, a resection with TEM can be performed and histology will determine whether this treatment is sufficient. In the colon, a formal resection is performed.
    • Hagitt level 4 is treated as a sessile tumor.

    Treatment of T1 sessile tumors in the rectum

    There is no consensus on treatment for these patients. Local resection using TEM as a curative treatment is an alternative if the following criteria are filled:

    • The tumor is less than 2.5-3 cm in diameter.
    • The tumor is of high or moderate differentiation. 
    • The tumor is not infiltrating deeper than to the upper part of the submucosa (Kikuchi sm1).
      • For sm2, the situation is assessed individually.
    • There is no sign of infiltration in the vein/lymph systems.
    • The tumor lies in an area of the rectum where a full wall resection can be performed such that a 1 cm free margin is achieved sideways (in the mucosa/intestinal wall around the tumor).

    The diagnostic evaluation should aim at determining whether the criteria are met before the operation. However, the final result depends on the histological examination of the TEM specimen. If all criteria are not met, then patients in good general health status should be re-operated with a formal rectum resection (TME) within a few weeks. The patient should be informed about this before the TEM operation.

    If all criteria are met, the risk for local recurrence is less than 10%. The patient must be monitored closely by rectal exploration, endoscopy, and rectal ultrasound. Possible recurrence can then be found at an early stage such that a curative operation is possible.

    Localized cancer (T1-T3)

    When the cancer is localized, the bowel segment including mesorectum can be removed with the tumor and the local lymph node stations along the veins. For radical surgery, draining lymph nodes must be removed along with the tumor. This will determine the length of the bowel that has to be removed. Cutting into the tumor must be avoided as this will increase the chance of spreading cancer cells.

    Locally advanced cancer (T4a)

    In locally advanced cancer, the bowel segment is removed with the infiltrated organ in en-bloc. A problem is that in approximately 25% of patients, fixation to surrounding tissue is caused by an inflammatory reaction and not direct cancer infiltration. To be certain of removing the tumor with wide enough margins, one risks removing organs which the pathology examination shows were  not infiltrated with cancer. "Trial excision" through the tumor between two organs may free cancer cells and reduce the prognosis. If tumor has infiltrated neighboring organs/structures, these must be removed en bloc. In around 70% of cases, there are cancer cells in infiltrated neighboring organs even if radiation therapy or chemotherapy is given. The patient must be operated at the level the tumor was before treatment and remove fibrosis and mucinous areas if the treatment is intended to cure the disease.

    Local recurrence

    In local relapse, estimation of the tumor limits are an even greater challenge. In such a case, free margins should also be achieved with extensive en bloc resections. However, a trial resection must often be performed with a frozen section biopsy of the resection edge to see if it is microscopically free.

    PROSEDYRER

    Tumor in the cecum and ascending colon

    General

    For cancer in the cecum and ascending colon a right-sided hemicolectomy and a standard resection of colon- and lymph nodes are performed.

    The ileocolica vessels are divided centrally.The right colic arteria which originates from the superior mesentric artery in only 15%, is also centrally divided.

     

    Equipment

    • Laparotomy- or laparascopic equipment

    Preparation

    Patient preparation:

    • bowel emptying. The routines variy between hospitals.
    • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addtition should have oral antibiotics from the day before the surgery.
    • thrombosis prophylaxis with low molecular weight heparin.

    During the surgery it is inserted:

    • epidural catheter for pain management.
    • urinary catheter.
    • naso-gastric tube which is removed by the end of the surgery.


    Implementation

    Laparoscopic right sided hemicolectomy

    Step 1 – Trochar insertion and diagnostic laparoscopy

    • The patient in anti-Trendelenburg position and turned to the left.
    • Trochar insertion with visiport medial to the left medioclavicular line at the level of umbilicus, possibly slightly more to the left in adipose patients. Thereafter 5 mm port medial to the left fossa, 5 mm in the right fossa and 5 mm in the epigastric to the left of the midline (12 mm in case of intracorporeal anastomosis). Avoid the inferior epigastric vessels and insertion of the trochar too low on the abdomen which may impede the angulation within the abdominal cavity.
    • Examine the primary tumor for perforation and/or infiltration into adjacent organs. Thereafter the liver and the total abdominal cavity is inspected with regard to metastases, peritoneal carsinomatosis (especially the pelvis and the paracolic gutters) and other pathology.

    Step2 – Release the transverse colon from the middle to the right flexure.

    • The gastrocolic ligament (the greater omentum) is opened and the cranial surface of the transverse mesenterium is freed from the middle of the transverse colon to the right flexure.
    • Dissect the whole width towards the root of the mesentery. The medial colic vessels will be visualized to the right of the duodenum. This plane is mainly avascular, but the vein between the gastrocolic trunc and the left gastroepiploic must be divided and secured.
    • If necessary introduce a longitudinal compress along the root of the transverse mesocolon.

    Step 3 – Perform central ligation of the vessels, lymph nodes and mesentery.

    • The patient in Trendenburg’s position, turned to the left.
    • Position the omentum above the liver, Lift the transverse colon cranially and luxate the small bowel package over the midline to the left.
    • Put tension to the ileocolic vessels. Try to localize the origin of the ileocolic vessels on the superior mesenteric vessels.
    • 2-3 cm distal to the origin the peritoneum is incised vertically, the incision is followed superior mesenteric vein to the dorsal surface of the mesenteric root.
    • Start distally and dissect on to the superior mesenteric vein and follow these until the ileocolic vessels. These are dissected free at the right side of the mesenteric vein and divided here. The ileocolic artery appears dorsal to the superior mesenteric vein in 75%, anterior in 25% of the patients. Avoid dissecting too far laterally (to the right) of the mesenteric vessels distally and at the ileocolic vessels which will result in remaining lymph nodes.
    • Continue along the right side of the mesenteric vein cranially to the ileocolic and identify a possible right colic artery departing from the superior mesenteric artery. This is found in 20% of the patients. Divide this similarly.
    • Continue the peritoneal incision from the root of the mesentery cranially on the dorsal aspect of the transversal mesentery.
    • Identify the middle colic vessels and extend the incision just on the right side of these.
    • Thereafter the transverse mesocolon is divided, including the vessels leaving from the middle colic artery to the right flexure. The latter are divided at the origin from the middle artery.
    • Dissect on to the bowel wall along the whole circumference where the transverse colon is to be transected.

    Step 4 – Dissect in the mesocolic plane on the dorsal aspect of the mesentery/ bowel wall.

    • Grip the ileocolic vessels and lift forward/laterally.
    • Incise peritoneum to the planned location for the ileal resection, around 8-10 cm orally to the ieocoecal valve. Maintain the vessel archades all along the ileum.
    • Dissect in the anatomical plane dorsal to the mesocolon of the transversal and  ascending colon and coecum. This is anterior to the uncinated process of the pancreas, anterior and caudally to the duodenum and in front of the Gerota’s capsule.
    • Develop the plane all along to the lateral abdominal wall till the anterior dissection plane is reached.
    • Divide the last adherances all the way from the dorsal aspect of the distal ileum and coecum and dissect further laterally from the coecum/ ascendens towards the flexure.

    Step 5 – Extracorporeal anastomosis

    • 5-6 cm transverse incision in the rectal sheath just cranially to the umbilicus. Protecting plastic.
    • Exteriorize the specimen with the ileum and the transverse colon. Either prepare an aniso-peristaltic or iso- peristaltic side-by-side anastomosis with stapler instrument.
    • Thereafter divide the specimen with the stapler.
    • Interiorize the bowel to the abdominal cavity.
    • Close the abdominal fascia and skin.
    • Control the rotation by laparoscopic inspection. Examine the total surgical area for possible operative injuries.

    Step 5 alternative – Intracorporeal anastomosis

    • Divide the ileum and transverse colon with stapler.
    • Position the specimen above the liver.
    • Prepare iso-peristatic anastomosis with stapler from the epigastric port: Enterotomy 1 cm from the end of the ileum and colotomy 7 cm from the end of the colon, the anastomosis is positioned anti-mesenterially.
    • The remaining bowel opening is closed with 3-0 Vicryl in one layer.
    • The specimen is removed through a suprapubic horizontal minilaparotomy. The abdominal wound is protected by plastic drape during the exteriorization.
    • Close the abdominal fascia and skin.

    Step 6 – Laparoscopic control and removal of ports.

    • Repeat inspection of the abdominal cavity.Control correct rotation of the anastomosis.
    • Examine the total abdominal for iatrogenic injuries.
    • Close the ports.

    Follow-up

    • The patient is mobilized in the evening the day of surgery, or possibly the next day.
    • The patient can start to drink and eat carefully on the first postoperative day.
    • The urinary catheter is removed on the fist postoperative day or when the patient is mobilized.
    • The epidural catheter is usually removed on the continues on peroral analgetics.

    Complications

    • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarcion and arrytmias and dysrhythmia may occur. Basilar atelectasis and/or pleural fluid and possibly pneumonia are more common.
    • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvis infections, diffuse or localized, in the absence of anastomosis leakage.
    • Intraabdominal bleeding, inclusive bleeding from anastomosis is relatively rare.
    • After open surgery wound dehiscence and infection in the abdominal wound occur varying degrees, from light superficial infection to abdominal wall abscess.
    • Paralytic ileus is common in the presence of another complication but can also appear without any specific cause.
    • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
    • Port-site hernia occurs after a laparoscopy.
    • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
    • Urinary retention

    Late complications

    • Ventral hernia in the abdominal wound may occur.
    • Postoperative ileus occurs in about 5%.
    Right Hemicolectomy

    Tumor in the right colic flexure

    General

    For cancer in the right colic flexure an extended right-sided hemicolectomy and a resection of colon- and lymph nodes are performed.

    Arteria ileocolica and colica media are divided centrally and the mesentery of transverse colon is divided slightly to the left for the arteria colica media.


    Equipment

    • Laparotomy- or laparascopic equipment

    Preparation

    Patient preparation:

    • bowel emptying. The routines variy between hospitals.
    • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addition should have oral antibiotics from the day before the surgery.
    • thrombosis prophylaxis with low molecular weight heparin.

    During the surgery it is inserted:

    • epidural catheter for pain management.
    • urinary catheter.
    • naso-gastric tube which is removed by the end of the surgery.

    Implementation

    A laparascopic right-sided hemicolectomy is performed. The surgery is identical with “Tumor in the cecum and ascending colon” except for the following:

    • After the arteria ileocolica is divided centrally one goes further up and the arteria colica media is divided centrally. The mesentery of transverse colon is divided to the left of the place where the colica media vessels are coming up in the mesentery.

    Laparoscopic right sided hemicolectomy

    Step 1 – Trochar insertion and diagnostic laparoscopy

    • The patient in anti-Trendelenburg position and turned to the left.
    • Trochar insertion with visiport medial to the left medioclavicular line at the level of umbilicus, possibly slightly more to the left in adipose patients. Thereafter 5 mm port medial to the left fossa, 5 mm in the right fossa and 5 mm in the epigastric to the left of the midline (12 mm in case of intracorporeal anastomosis). Avoid the inferior epigastric vessels and insertion of the trochar too low on the abdomen which may impede the angulation within the abdominal cavity.
    • Examine the primary tumor for perforation and/or infiltration into adjacent organs. Thereafter the liver and the total abdominal cavity is inspected with regard to metastases, peritoneal carsinomatosis (especially the pelvis and the paracolic gutters) and other pathology.

    Step2 – Release the transverse colon from the middle to the right flexure.

    • The gastrocolic ligament (the greater omentum) is opened and the cranial surface of the transverse mesenterium is freed from the middle of the transverse colon to the right flexure.
    • Dissect the whole width towards the root of the mesentery. The medial colic vessels will be visualized to the right of the duodenum. This plane is mainly avascular, but the vein between the gastrocolic trunc and the left gastroepiploic must be divided and secured.
    • If necessary introduce a longitudinal compress along the root of the transverse mesocolon.

    Step 3 – Perform central ligation of the vessels, lymph nodes and mesentery.

    • The patient in Trendenburg’s position, turned to the left.
    • Position the omentum above the liver, Lift the transverse colon cranially and luxate the small bowel package over the midline to the left.
    • Put tension to the ileocolic vessels. Try to localize the origin of the ileocolic vessels on the superior mesenteric vessels.
    • 2-3 cm distal to the origin the peritoneum is incised vertically, the incision is followed superior mesenteric vein to the dorsal surface of the mesenteric root.
    • Start distally and dissect on to the superior mesenteric vein and follow these until the ileocolic vessels. These are dissected free at the right side of the mesenteric vein and divided here. The ileocolic artery appears dorsal to the superior mesenteric vein in 75%, anterior in 25% of the patients. Avoid dissecting too far laterally (to the right) of the mesenteric vessels distally and at the ileocolic vessels which will result in remaining lymph nodes.
    • Continue along the right side of the mesenteric vein cranially to the ileocolic and identify a possible right colic artery departing from the superior mesenteric artery. This is found in 20% of the patients. Divide this similarly.
    • Continue the peritoneal incision from the root of the mesentery cranially on the dorsal aspect of the transversal mesentery.
    • Identify the middle colic vessels and extend the incision just on the right side of these.
    • Thereafter the transverse mesocolon is divided, including the vessels leaving from the middle colic artery to the right flexure. The latter are divided at the origin from the middle artery.
    • Dissect on to the bowel wall along the whole circumference where the transverse colon is to be transected.

    Step 4 – Dissect in the mesocolic plane on the dorsal aspect of the mesentery/ bowel wall.

    • Grip the ileocolic vessels and lift forward/laterally.
    • Incise peritoneum to the planned location for the ileal resection, around 8-10 cm orally to the ieocoecal valve. Maintain the vessel archades all along the ileum.
    • Dissect in the anatomical plane dorsal to the mesocolon of the transversal and  ascending colon and coecum. This is anterior to the uncinated process of the pancreas, anterior and caudally to the duodenum and in front of the Gerota’s capsule.
    • Develop the plane all along to the lateral abdominal wall till the anterior dissection plane is reached.
    • Divide the last adherances all the way from the dorsal aspect of the distal ileum and coecum and dissect further laterally from the coecum/ ascendens towards the flexure.

    Step 5 – Extracorporeal anastomosis

    • 5-6 cm transverse incision in the rectal sheath just cranially to the umbilicus. Protecting plastic.
    • Exteriorize the specimen with the ileum and the transverse colon. Either prepare an aniso-peristaltic or iso- peristaltic side-by-side anastomosis with stapler instrument.
    • Thereafter divide the specimen with the stapler.
    • Interiorize the bowel to the abdominal cavity.
    • Close the abdominal fascia and skin.
    • Control the rotation by laparoscopic inspection. Examine the total surgical area for possible operative injuries.

    Step 5 alternative – Intracorporeal anastomosis

    • Divide the ileum and transverse colon with stapler.
    • Position the specimen above the liver.
    • Prepare iso-peristatic anastomosis with stapler from the epigastric port: Enterotomy 1 cm from the end of the ileum and colotomy 7 cm from the end of the colon, the anastomosis is positioned anti-mesenterially.
    • The remaining bowel opening is closed with 3-0 Vicryl in one layer.
    • The specimen is removed through a suprapubic horizontal minilaparotomy. The abdominal wound is protected by plastic drape during the exteriorization.
    • Close the abdominal fascia and skin.

    Step 6 – Laparoscopic control and removal of ports.

    • Repeat inspection of the abdominal cavity.Control correct rotation of the anastomosis.
    • Examine the total abdominal for iatrogenic injuries.
    • Close the ports.

    Follow-up

    • The patient is mobilized in the evening the day of surgery, or possibly the next day.
    • The patient can start to drink and eat carefully on the first postoperative day.
    • The urinary catheter is removed on the first postoperative day or when the patient is mobilized.
    • The epidural catheter is usually removed on the continues on peroral analgetics.

    Complications

    • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarction and arhythmias and dysrythmia may occur. Basal atelectasis and/or pleural fluid and possibly pneumonia are more common.
    • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare, in the abscence of anastomosis leakage.
    • Intraabdominal bleeding, including bleeding from anastomosis is relatively rare.
    • After an open surgery wound dehiscence and infection in the abdominal wound occur to varying degrees, from light superficial infection up to an abdominal wall abscess.
    • Paralytic ileus is common in the presence of another complication but can also appear without any specific cause.
    • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
    • Port-site hernia occurs after a laparoscopy.
    • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
    • Urinary retention.

    Late complications

    • Ventral hernia in the abdominal wound may occur.
    • Postoperative ileus occurs in about 5%.
    Extended right hemicolectomy

    Tumor in the transverse colon

    General

    For cancer in the transverse colon, all of the transverse colon and both the right colic flexure and the left colic flexure are removed. A standard resection of colon- and lymph nodes are performed.

    The arteria colica media is divided centrally.


    Equipment

    • Laparotomy- or laparascopic equipment

    Preparation

    Patient preparation:

    • bowel emptying. The routines variy between hospitals.
    • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addtition should have oral antibiotics from the day before the surgery.
    • thrombosis prophylaxis with low molecular weight heparin.

    During the surgery it is inserted:

    • epidural catheter for pain management.
    • urinary catheter.
    • naso-gastric tube which is removed by the end of the surgery.

    Implementation

    Both flexures are included and a resection is performed as illustrated. If the colonic anastomosis does not fall nicely, cecum and all of ascendens can optionally be removed and the anastomosis is performed between the terminal ileum and the descending colon.

    Follow-up

    • The patient is mobilized in the evening the day of surgery, or possibly the next day.
    • The patient can carefully start to drink and eat on the first postoperative day.
    • The urinary catheter is removed on the first postoperative day or when the patient is mobilized.
    • The epidural catheter is usually removed on the continues on peroral analgetics. 

    Complications

    • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarction and arrythmias and dysrhythmia may occur. Basal atelectasis and/or pleural fluid and possibly pneumonia are more common.
    • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare in the absence of anastomosic leakage.
    • Intraabdominal bleeding, including bleeding from anastomosis is relatively rare.
    • After open surgery wound dehiscence and infection in the abdominal wound occur to varying degrees, from light superficial infection to abdominal wall abscess.
    • Paralytic ileus is common in the presence of another complication, but can also appear without any specific cause.
    • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
    • Port-site hernia occurs after a laparoscopy.
    • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
    • Urinary retention.

    Late complications

    • Ventral hernia in the abdominal wound may occur.
    • Postoperative ileus occurs in about 5%.
    Resection of the transverse colon

    Tumor in the left colic flexure

    General

    For cancer in the left colic flexure both the middle and left colic arteries have to be divided centrally. 

    As a minimum, the intestine on the right side of the transverse colon to the transition descending colon/sigmoid is resected. In emergencies, and possibly in those cases where the transverse/sigmoid anastomosis does not fall nicely, the entire right colon is removed and an ileo/sigmoid anastomosis is performed.

    Equipment

    • Laparotomy- or laparascopic equipment

    Preparation

    Bowel emptying is not necessary.

    Patient preparation:

    • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addtition should have oral antibiotics from the day before the surgery.
    • thrombosis prophylaxis with low molecular weight heparin.

    During the surgery it is inserted:

    • epidural catheter for pain management.
    • urinary catheter.
    • naso-gastric tube which is removed by the end of the surgery.

    Implementation

    There are two alternative methods:

    • At emergency surgery of ileus/perforation an extended right-sided hemicolectomy is performed in addition to resection of the intestinal segment  around  the left colic flexure to the lower part of the descending colon.
    • At elective surgery one is dividing distally in the same level, but cecum ascending colon and the right part of transverse colon may be retained if the bowel is released and a good anastomosis without any tensioning is performed.

    In both cases a standard lymph node resection is performed.

    Colica media is divided centrally and colica sinistra is divided by mesenterica inferior.


    Follow-up

      • The patient is mobilized in the evening the day of surgery, or possibly the next day.
      • The patient can carefully start to drink and eat on the first postoperative day.
      • The urinary catheter is removed on the first postoperative day or when the patient is mobilized.
      • The epidural catheter is usually removed on the continues on peroral analgetics.

      Complications

      • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarction and arrythmias and dysrhythmia may occur. Basal atelectasis and/or pleural fluid and possibly pneumonia are more common.
      • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare in the absence of anastomosic leakage.
      • Intraabdominal bleeding, including bleeding from anastomosis is relatively rare.
      • After open surgery wound dehiscence and infection in the abdominal wound occur to varying degrees, from light superficial infection to abdominal wall abscess.
      • Paralytic ileus is common in the presence of another complication, but can also appear without any specific cause.
      • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
      • Port-site hernia occurs after a laparoscopy.
      • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
      • Urinary retention.

      Late complications

      • Ventral hernia in the abdominal wound may occur.
      • Postoperative ileus occurs in about 5%.
      Tumor in the left colic flexure

      Tumor in the descending colon

      General

      For cancer in the descending colon, a left-sided hemicolectomy and a standard bowel- and lymph node resection are performed. The bowel is divided to the left on the transverse colon and upwards on the rectum. The distal sigmoid colon is not being retained because the blood supply may not remain satisfactory.

      The inferior mesenteric veins are divided centrally. (The artery at the aorta and the vein close to the edge of the pancreas.)


      Equipment

      • Laparotomy- or laparascopic equipment

      Preparation

      Bowel emptying is not necessary.

      Patient preparation:

      • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addition should have oral antibiotics from the day before the surgery.
      • thrombosis prophylaxis with low molecular weight heparin.

      During the surgery it is inserted:

      • epidural catheter for pain management.
      • urinary catheter.
      • naso-gastric tube which is removed by the end of the surgery.

      Implementation

      The procedure is performed in the same way as sigmoid resection. The difference is that the oral bowel end here is divided at the left on the transverse colon

      Laparoscopic sigmoid resection.

      Step 1 – Trochar insertion and diagnostic laparoscopy

      • Trocharinsertion with visiport just to the right of umbilicus, 5 mm epigastric port, and 12 mm port in the right fossa and 5 mm in the left fossa and suprapubically. Avoid the inferior epigastric vessels and insertion of the trochar too low on the abdomen which may impede the angulation within the abdominal cavity.
      • Examine the primary tumor for perforation and/or infiltration into adjacent organs. Thereafter the liver and the total abdominal cavity is inspected with regard to metastases, peritoneal carsinomatosis (especially the pelvis and the paracolic gutters) and other pathology.

      Step2 – Release the mesentery and colon (left transversal, left flexure and descending colon) in the mesocolic plane

      • The patient in Trendelenburg’s position tilted towards the right. Position the omentum over the liver and put the small bowel package over the midline to the right. If necessary apply an extra trochar suprapubically to expose the ligament of Treitz.
      • Open the peritoneum on the posterior abdominal wall medially to the origin of the inferior mesenteric artery after possible adherances are released at the ligament of Treitz.
      • Continue in the mesocolic plane towards the left flexure and divide the inferior mesenteric vein. Dissect in the mesocolic plane cranially (avoid dissection dorsally to the pancreas) and continue anteriorly to the pancreas and into the lesser sac. Be aware that arcade vessels can be located relatively centrally along the colon.
      • Divide adherances along the tail of the pancreas all the way to the lateral abdominal wall. Continue under the left flexure and descending colon (in front of the pancreas and the left kidney).
      • Continue in front of the colon where the gastro-colic ligament is divided just caudally to the gastro-epiploic vessels, divide the splenocolic ligament.
      • Divide the peritoneum laterally the descending colon along “the white line of Tod”. Carry through till the anterior and dorsal dissection have met and the left flexure and descending colon are completely free.

      Step 3 – Central resection of the inferior mesenteric artery

      • Lift sigmoid and its mesentery anteriorly and to the left and put it on tension. Incise the peritoneum at the pelvic entrance till the origin of the inferior mesenteric artery in line between the posterior abdominal wall and the sigmoid mesentery.
      • Continue in the dorsal mesocolic plane behind the sigmoid mesentery towards the lateral abd ominal wall (avoid left ureter).
      • Dissect the origin of the inferior mesenteric artery at the aorta and divide with hemlock. During this dissection the main sympathetic nerves must be visualized and retracted posteriorly to avoid injury. Avoid dissection into the parietal fascia in front of the aorta and posterior abdominal wall. (If the proper vessel wall is visualised the dissection has been carried on too deeply and the nerve plexus may have been injured).

      Step 4 – Finish the dissection of the sigmoid

      • Grip the divided mesenteric inferior artery and lift it forward.
      • Continue the dissection in the mesocolic plane till the lateral abdominal wall behind the all descending colon to the upper rectum. Carefully sweep the nerves dorsally.
      • Finish the peritoneal incision medially and dorsally till the point of the division of the rectum.
      • From the anterior free the sigmoid until the whole left colon, sigmoid and upper rectum is completely free.

      Step 5 – Divide the bowel on the oral rectum

      • Divide the mesorectum and the superior rectal vessels and prepare the bowel tube.
      • Divide with stapler instrument. The distal sigmoid must be completely resected to ensure adequate circulation in the anal bowel tube

      Step 6 – Exteriorize the specimen and oral bowel end

      • Make a 6 cm incision transversally above the symphysis (Pfannenstihl incision).
      • Incise the fascia in front of the rectus muscle similarly.
      • Lift both edges of the fascia with Kocker’s forceps and dissect it off the underlying muscle. The dissection must be sharp in the midline.
      • Retract both rectus muscles from the midline.
      • Incise the peritoneum.
      • Apply plastic protection to the edges of the wound and exteriorize the specimen with the central vessels.
      • Divide mesentery and bowel at intended location.
      • Cut with scissors in the vascular arcade close to the bowel to visualize adequate blood circulation in the oral bowel end (adequate systolic blood pressure during the test?). Move further orally on the colon in case of inadequate bleeding.
      • Place the “hat” of the circular stapler with purse-string sutures.
      • Interiorize the colon.
      • Close the abdomen.

      Step 7 – Anastomosis

      • Flush the rectum.
      • Insert the circular stapler and perforate the bowel with the pin just in front of or behind the staple row.
      • Attach oral and anal parts of the stapler while controlling the rotation of the bowel.
      • Close the stapler and visually control for possible interposition.
      • Flush the anastomosis.
      • Test the anastomosis enclosed by water and with air in the rectum.
      • Retract the omentum over the small bowel.

      Step 8 – Laparoscopic control and closure of ports

      • Repeat inspection of the abdominal cavity for possible iatrogenic injury.
      • Close the ports.

      Follow-up

      • The patient is mobilized in the evening the day of surgery, or possibly the next day.
      • The patient can carefully start to drink and eat on the first postoperative day.
      • The urinary catheter is removed on the first postoperative day or when the patient is mobilized.
      • The epidural catheter is usually removed on the continues on peroral analgetics.

      Complications

      • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarction and arrythmias and dysrhythmia may occur. Basal atelectasis and/or pleural fluid and possibly pneumonia are more common.
      • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare in the absence of anastomosic leakage.
      • Intraabdominal bleeding, including bleeding from anastomosis is relatively rare.
      • After open surgery wound dehiscence and infection in the abdominal wound occur to varying degrees, from light superficial infection to abdominal wall abscess.
      • Paralytic ileus is common in the presence of another complication, but can also appear without any specific cause.
      • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
      • Port-site hernia occurs after a laparoscopy.
      • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
      • Urinary retention.

      Late complications

      • Ventral hernia in the abdominal wound may occur.
      • Postoperative ileus occurs in about 5%.
      Left-sided hemicolectomy

      Tumor in the sigmoid colon

      General

      If cancer in the sigmoid colon, a sigmoid colon resection and a standard bowel- and lymph node resection are performed.

      The bowel is put off on the colon descending and on the very top of the rectum.

      The inferior mesenteric is divided centrally.


      Equipment

      • Laparotomy- or laparascopic equipment

      Preparation

      Patient preparation:

      • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addition should have oral antibiotics from the day before the surgery.
      • thrombosis prophylaxis with low molecular weight heparin.

      During the surgery it is insterted:

      • epidural catheter for pain management.
      • urinary catheter.
      • naso-gastric tube which is removed by the end of the surgery.

      Implementation

      Laparoscopic sigmoid resection.

      Step 1 – Trochar insertion and diagnostic laparoscopy

      • Trocharinsertion with visiport just to the right of umbilicus, 5 mm epigastric port, and 12 mm port in the right fossa and 5 mm in the left fossa and suprapubically. Avoid the inferior epigastric vessels and insertion of the trochar too low on the abdomen which may impede the angulation within the abdominal cavity.
      • Examine the primary tumor for perforation and/or infiltration into adjacent organs. Thereafter the liver and the total abdominal cavity is inspected with regard to metastases, peritoneal carsinomatosis (especially the pelvis and the paracolic gutters) and other pathology.

      Step2 – Release the mesentery and colon (left transversal, left flexure and descending colon) in the mesocolic plane

      • The patient in Trendelenburg’s position tilted towards the right. Position the omentum over the liver and put the small bowel package over the midline to the right. If necessary apply an extra trochar suprapubically to expose the ligament of Treitz.
      • Open the peritoneum on the posterior abdominal wall medially to the origin of the inferior mesenteric artery after possible adherances are released at the ligament of Treitz.
      • Continue in the mesocolic plane towards the left flexure and divide the inferior mesenteric vein. Dissect in the mesocolic plane cranially (avoid dissection dorsally to the pancreas) and continue anteriorly to the pancreas and into the lesser sac. Be aware that arcade vessels can be located relatively centrally along the colon.
      • Divide adherances along the tail of the pancreas all the way to the lateral abdominal wall. Continue under the left flexure and descending colon (in front of the pancreas and the left kidney).
      • Continue in front of the colon where the gastro-colic ligament is divided just caudally to the gastro-epiploic vessels, divide the splenocolic ligament.
      • Divide the peritoneum laterally the descending colon along “the white line of Tod”. Carry through till the anterior and dorsal dissection have met and the left flexure and descending colon are completely free.

      Step 3 – Central resection of the inferior mesenteric artery

      • Lift sigmoid and its mesentery anteriorly and to the left and put it on tension. Incise the peritoneum at the pelvic entrance till the origin of the inferior mesenteric artery in line between the posterior abdominal wall and the sigmoid mesentery.
      • Continue in the dorsal mesocolic plane behind the sigmoid mesentery towards the lateral abd ominal wall (avoid left ureter).
      • Dissect the origin of the inferior mesenteric artery at the aorta and divide with hemlock. During this dissection the main sympathetic nerves must be visualized and retracted posteriorly to avoid injury. Avoid dissection into the parietal fascia in front of the aorta and posterior abdominal wall. (If the proper vessel wall is visualised the dissection has been carried on too deeply and the nerve plexus may have been injured).

      Step 4 – Finish the dissection of the sigmoid

      • Grip the divided mesenteric inferior artery and lift it forward.
      • Continue the dissection in the mesocolic plane till the lateral abdominal wall behind the all descending colon to the upper rectum. Carefully sweep the nerves dorsally.
      • Finish the peritoneal incision medially and dorsally till the point of the division of the rectum.
      • From the anterior free the sigmoid until the whole left colon, sigmoid and upper rectum is completely free.

      Step 5 – Divide the bowel on the oral rectum

      • Divide the mesorectum and the superior rectal vessels and prepare the bowel tube.
      • Divide with stapler instrument. The distal sigmoid must be completely resected to ensure adequate circulation in the anal bowel tube

      Step 6 – Exteriorize the specimen and oral bowel end

      • Make a 6 cm incision transversally above the symphysis (Pfannenstihl incision).
      • Incise the fascia in front of the rectus muscle similarly.
      • Lift both edges of the fascia with Kocker’s forceps and dissect it off the underlying muscle. The dissection must be sharp in the midline.
      • Retract both rectus muscles from the midline.
      • Incise the peritoneum.
      • Apply plastic protection to the edges of the wound and exteriorize the specimen with the central vessels.
      • Divide mesentery and bowel at intended location.
      • Cut with scissors in the vascular arcade close to the bowel to visualize adequate blood circulation in the oral bowel end (adequate systolic blood pressure during the test?). Move further orally on the colon in case of inadequate bleeding.
      • Place the “hat” of the circular stapler with purse-string sutures.
      • Interiorize the colon.
      • Close the abdomen.

      Step 7 – Anastomosis

      • Flush the rectum.
      • Insert the circular stapler and perforate the bowel with the pin just in front of or behind the staple row.
      • Attach oral and anal parts of the stapler while controlling the rotation of the bowel.
      • Close the stapler and visually control for possible interposition.
      • Flush the anastomosis.
      • Test the anastomosis enclosed by water and with air in the rectum.
      • Retract the omentum over the small bowel.

      Step 8 – Laparoscopic control and closure of ports

      • Repeat inspection of the abdominal cavity for possible iatrogenic injury.
      • Close the ports.

      Follow-up

      • The patient is mobilized in the evening the day of surgery, or possibly the next day.
      • The patient can carefully start to drink and eat on the first postoperative day.
      • The urinary catheter is removed on the first postoperative day or when the patient is mobilized.
      • The epidural catheter is usually removed on the continues on peroral analgetics.

      Complications

      • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarction and arrythmias and dysrhythmia may occur. Basal atelectasis and/or pleural fluid and possibly pneumonia are more common.
      • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare in the absence of anastomosic leakage.
      • Intraabdominal bleeding, including bleeding from anastomosis is relatively rare.
      • After open surgery wound dehiscence and infection in the abdominal wound occur to varying degrees, from light superficial infection to abdominal wall abscess.
      • Paralytic ileus is common in the presence of another complication, but can also appear without any specific cause.
      • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
      • Port-site hernia occurs after a laparoscopy.
      • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
      • Urinary retention.

      Late complications

      • Ventral hernia in the abdominal wound may occur.
      • Postoperative ileus occurs in about 5%.
      Sigmoid resection

      Surgery for locally advanced colon cancer

      General

      Locally advanced colon cancer grows into surrounding organs. Which organs that are involved depends on the location of the cancer. Due to its mobility, sigmoid colon cancer often grows into the pelvic organs. This can also occur when the cecum is mobile and in rare cases in a very long transverse colon.

      When there is infiltration into essential structures such as veins, nerves, and bone of the posterior abdominal wall, it may be appropriate to administer pre- or postoperative radiation. The advantage of postoperative radiation is that the area with highest risk of recurrence is identified and can be marked with clips during surgery to reduce the radiation field as much as possible.

      The condition is often combined with peritoneal carcinomatosis which will be a contraindication to extensive surgery.

      A palliative resection may be appropriate if the condition clearly influences quality of life.

      Indication

      • Colon cancer (locally advanced/local relapse)

      Goals

      • Curation
      • Palliation
      • Improve/ prevent extensive reduction of life quality

      Equipment

      • Laparotomy tray
      • Bookwalter's self-retaining retractor
      • Stapling instruments: cross stapling/closing-deviding/circular

      Preparation

      • The patient must be informed that the resection will not be performed if distant metastases can be verified in the abdomen during the procedure.
      • Preoperative bowel emptying is not done as this does not reduce the frequency of anastomsis leakage or infection.
      • Thrombosis prophylaxis
      • Antibiotic prophylaxis 
      • Epidural catheter is inserted for postoperative pain treatment for 1-3 days.
      • The patient lies in the supine position on the operating table.
      • The operation is carried out under general anasthesia.

      Implementation

      • A mid-line incision curving to the right of the navel is usually made.
      • The tumor with the adherent organs are removed en-bloc.
      • The abdomen is washed with a cytotoxic solution if there is a possibility for peritoneal tumor growth, or there has been peroperative spillage of bowel content.
      • The abdomen is closed.
      • A drain is installed only if there is increased risk of anastomosis leakage or bleeding.

      Follow-up

      • The patient may be mobilized as early as possible.
      • The patient may start to eat and drink on the first postoperative day.
      • Bladder catheter is removed on the first postoperative day or when the patient is mobilized.
      • The drain is removed when there is no longer fresh blood, usually after 2-3 days.
      • The epidural catheter is removed usually after 2-3 days and the patient is given oral analgesic.
      • The time of discharge depends on what type of resection is performed and possible complications.

      Complications from surgery 

      Early

      • Cardiopulmonary complications depend on the patient general health status, operation length and extensiveness.
      • In a colon resection, postoperative mortality is 0-2%.
      • Leakage from the bladder/urether can occur.
      • Anastomosis leakage can occur.

      Delayed

      • Ventral hernias in the abdominal wound can occur
      • Postoperative ileus can occur.  
      • Functional handicaps depend on which organs are resected.
      Locally advanced colon cancer/local relapseLocally advanced colon cancer/local relapse. Locally advanced colon cancer/local relapse.Locally advanced colon cancer/local relapse.
      Locally advanced colon cancer/local relapse.

      Surgery of rectal cancer

      Measurement of levels

      Measuring levels by flexible endoscopy is not accurate. Usually the distance will be shorter than estimated by the endoscopist. It is therefore very important that all lesions measured by colonoscope at a level of <25 cm from the anal verge must be reexamined with a rigid scope to achieve a correct measurement. CT, CT-colography and MRI of the rectum can also be helpful in defining the level of the tumor.

      The rectum is the bowel from the dentate line in the anal canal til 15 cm above this as measured with a rigid scope. Malignant tumor with the anal border in this area is defined as a rectal cancer in Norway. (Other definitions are used in other countries, for instance 12/16 cm from the anal verge).

      Measurement with a rigid sigmoidoscope:

      • Lower rectum. From the dentate line till 6 cm above the anal verge.
      • Middle rectum. 7-10 cm above the anal verge.
      • Upper rectum. 11-15 cm above the anal verge.
      • The peritoneal fold is mostly at 10 cm, which is most often equivalent to Huston’s 2.nd fold seen at endoscopy. The rectosigmoid flexure is the bowel at 16-20 cm above the anal verge. When the lover level of the tumor is within this region it is by definition a cancer of the rectosigmoid flexure.

      The sigmoid stretches orally from 21 cm.

      PROSEDYRER

      Transanal endoscopic microsurgery (TEM)

      General

      Using transanal endoscopic microsurgery (TEM) tumors in the rectum can be removed with far greater precision and overview than other endoscopic or conventional transanal techniques allow. This provides greater confidence of complete removal of the lesion and that local recurrences are avoided. Complete resection also provides a correct histological diagnosis.

      Cancer in the head of pedunculated polyp

      • For T1 tumor in pedunculated polyp, Haggitt level 1 and 2, removed by endoscopic snare resection with macro- and microscopic definitely free resection margins, the treatment is considered as completed. (Similarly in colon.)
      • For Haggitt level 3 the resection margins is often questionable. In rectum a resection of the area can then be performed by TEM, and histology will clarify whether this is adequate treatment. (In colon a formal resection must be performed.)
      • Haggitt level 4 is treated as a sessile tumor.

      Cancer of sessile polyp

      TEM is the main method for removing large premalignant polyps in the rectum. Polyps up to 10-12 cm in diameter may be removed by TEM, including polyps growing around the circumference of the intestine, and are located in the area of the dentate line up to about 15 cm above the anal opening.

      For infiltrating cancer local excision by TEM  is a good option for curative treatment if the following criteria are met:

      • The tumor is less than 2.5 to 3 cm in diameter
      • The tumor is high or moderately differentiated
      • The tumor does not invade deeper than the upper part of the submucosa (Kikuchi sm1)
        • For sm1 there is an agreement that TEM excision is curative when  performed adequately
        • For sm2 there is no agreement that TEM is sufficiently radical and these patients must be considered individually
      • There are no signs of infiltration in vessels or lymphatic infiltration
      • The location of the rectal tumor is in an area where performing a full wall resection is possible, and one cm free margin laterally is achievable (in mucosa/intestinal wall surrounding the tumor)

      It is being attempted to ascertain whether these criteria are met at the preoperative staging assessment, but a final and correct answer is only available after histological examination of the TEM sample. The TEM procedure is therefore often called a diagnostic excision biopsy and histological response will decide whether the procedure is sufficiently radical.

      If all criteria are met, the risk of local recurrence is less than 10%. Patients must be carefully controlled by rectal exploration, endoscopy and possibly rectal ultrasound. Any recurrence may then be detected at an early stage, and a curative reoperation can be performed.

      If all criteria are note met, patients in good general condition should be reoperated with total mesorectal excision (TME) within a few weeks. The patient should have information and be aware of this before the TEM operation.

      In very old patients and patients with poor general condition TEM may be appropriate as a compromise operation also for deep T1 and at T2 tumors. The risk of local recurrence is approximately 30% for this group, but if radiation therapy is given additionally it will be reduced, possibly in combination with chemotherapy. This should be assessed individually based on the risk of side effects. Disadvantage of TEM is that the surgery usually requires general anesthesia, and therefore is more straining for the patient than other endoscopic techniques.

      Equipment

        • A operating rectoscope ,4 centimeter in diameter and 15 or 25 centimeter in length, is used. This is fixed on a movable holder mounted to the operation table.
        • The optical system is put into place, there is binocular optics with six times magnification and a good three-dimensional image. A camera for view on a screen (2D) may also be connected.
        • There are three working channels for grasping forceps, diathermy knife/needle holder and suction.

        Preparation

          • Thorough preoperative bowel emptying is necessary. Oral laxative is administered the day before the surgery and water enema the day of surgery.
          • Thrombosis- and antibiotic prophylaxis are administered. The patient needs a urinary catheter.
          • The patient is positioned on the operating table depending on the location of the tumor around the circumference. The position does not change during the procedure, but the operating table can be tilted if necessary.
          • The operation is usually performed under general anesthesia and with full muscle relaxation. Exceptionally the operation is performed under spinal anesthesia.

          Implementation

          • The rectoscope is put in place and a intraluminal pressure of approximately 10 mm Hg is being established.
          • A suction is inserted to remove smoke after diathermy, fluids and possibly blood.
          • With grips pliers in the left hand and dissecting instruments or needle holder in the right hand, resection and suture of the defect in the intestinal wall are performed.
          • If the patient is fully relaxed with low intraabdominal pressure in order to distend the rectum and the polyp is not too big, a good visualization of the operation field is usually possible. If the polyp is growing very exophytic, and possibly has a large diameter (> 5.6 centimeters) the lumen will often be filled out after some dissection and this will complicate the overview.

          TEM is technically difficult because of the small space in the rectoscope with three working intruments which easily collide with each other. When the rectoscope is mounted, there is a limited area of access to the rectal wall. It is therefore necessary to move and angle the rectoscope repeated times to reach the areas to be dissected or sutured.When everything functions optimally there is however good overview, and the different layers of the bowel wall are defined and it is possible to dissect submucosa or between the muscle layers in the muscularis propria or perirectal fat tissue (full wall resection).

          Full wall resection is the quickest and most simple method and is preferred in the areas of the rectum where the entire wall can be removed. Distally, the external sphincter will be damaged and cranially on the anterior rectal wall, the abdominal cavity will be opened with a full wall resection. In these two areas, only a mucosal resection should be performed.

          When operating for cancer a full wall resection is always the intention.

          Follow-up

          The patient may begin to drink, eat and mobilize immediately after surgery. The catheter is removed as soon as the patient is mobilized and no later than the first postoperative day.

          Oral analgesics is administered if required. There is usually minimal pain associated with the postoperative phase, but sutures in and close to the dentate line may be painful.

          Patients are usually discharged on the first postoperative day. For very large resections or increased risk of infection the patient stays hospitalized for three-four days for observation.

          Complications

          • Serious complications after TEM are rare.
          • Moderate fever (up to 38.5 ° C) and CRP increase to 200 is normal and does not indicate a complication.
          • Infection originating from the perirectal pocket that appears after suture of the intestinal wall may occur. An abscess usually drains itself through the sutures and antibiotics for some days are sufficient treatment. In rare cases (1-2 %), the patient gets a serious perirectal infection, possibly with sepsis.
          • Postoperative bleeding in the form of blood seepage is common. Hematoma in perirectal pocket often leads to infection. In some cases (about 5 %) a major bleeding may occur 6-10 days after surgery and a doctor should be consulted.The bleeding usually stops spontaneously.
          • Postoperative perforation of the intestine to free abdominal cavity is very rare. The condition usually requires reoperation and construction of a stoma.

          Control for TEM for cancer

          The patients should have follow- up controls at the surgical ward which carried out the operation.

          There should be controls at least every six months for three years. Thereafter annually up to the fifth follow-up year. At every control a rectal examination, endoscopy and possibly rectal ultrasound are performed. This is sufficient if R0 resection with good margins at T1 sm1 is performed.

          If a TEM is performed as a compromise at deep T1 or T2 tumor, and new treatment is relevant in case of local-regional recurrence, a control with MRI of the pelvis should be considered, particularly if the tumor was above the level that can be reached with the fingers during exploration. Additionally the CEA may be controlled. CT for detection of distant metastases may be considered individually.

          Low anterior resection of rectal cancer

          General

          Principles for circumferential dissection

          The dissection must be performed as a TME (total mesorectal excision) as described by Heald. A sharp, visually controlled, dissection is performed in the plane between the visceral (Told) and parietal mesocolic/mesorectal fascia.

          This plane is identified at open operation by primarily freeing the sigmoid from the lateral abdominal wall continuing medially for the whole mesosigmoid till the central part of the posterior abdominal wall. The autonomic nerves and ureter will be left unharmed on the posterior abdominal wall. Continue in the same plane at the pelvic entrance.

          Thereafter the dissection is continued medially. Vessels and lymph nodes are divided at the proper level, the bowel is divided and can be pulled forward. Sharp, visually led dissection is continued in the mesorectal (“holy”) plane on the outside of the mesorectal fascia into the pelvis. The plane is usually easy to identify posteriorly and in front – at the back of the vesicles and prostate in men, the vagina in women. The proper plane should first be identified and followed posteriorly far into the pelvis, thereafter briefly at the front. The plane is more difficult to define laterally, especially at 10 and 2 o’clock. The dissection here should only be performed after the initial posterior and anterior dissection. Functionally important autonomic nerves are located just on the outside of the proper plane and will be injured by an improper dissection. Dissection on the inside of the proper plane will increase the risk for local recurrence.

          The quality of the resection can be visualized by inspection of the specimen. This should have an intact, even and smooth mesorectal fascia covering the mesorectal fat. In scientific studies it is customary to grade the appearance of the specimen and this also ought to be performed in clinical routine and described in the surgical record:

          • Grade A: Intact mesorectal fascia on the whole specimen
          • Grade B: Cuts in the mesorectal fascia, none onto the outside of the bowel
          • Grade C: Cuts in the mesorectal fascia onto the rectal wall

          The quality of the dissection can further be estimated by the integrity of the parietal fascia on the posterior abdominal/ pelvic wall. This should be intact and cover aorta and nerves.

          Principles for circumferential dissection when a low anterior resection may be performed while anastomosis is considered too risky.

          A standard TME is performed to the pelvic floor. When an anastomosis is no option the alternatives are:

          • Low Hartmann’s procedure. Rectum is divided distally.
          • Intersfincteric amputation.

          Standard TME is performed till the anal canal. A minimal skin incision is performed from below followed by an intersfincteric dissection. This way a large defect in the pelvic floor and skin is avoided and there are few healing problems. A short rectal stump, as in the Hartmann’s procedure, is avoided which can give rise to leakage and pelvic infection.

          Principles for regional lymph node dissection

          • For cancer in the rectosigmoid flexure the vessels/lymph nodes should be resected as in sigmoid cancer, which means at the origin of the inferior mesenteric artery at the aorta.
          • For cancer in the upper rectum it is probably adequate to resect the inferior mesenteric artery just distal to the origin of the left colic artery with removal of the local lymph nodes. Fat and lymph nodes in the apical station may be removed even if the artery is resected distal to the left colic artery.
          • For cancer in the middle/lower rectum the vessels/lymph nodes are resected just distal to the origin of the left colic artery.

          Principles for division of the rectum and mesorectum during low anterior resection.

          Orally the bowel is resected between the sigmoid and descending colon. The blood circulation of the oral bowel end must be inspected. If this seems inadequate the resection should be performed more orally. The left flexure must frequently be mobilized to obtain adequate length of the oral bowel to obtain a tension free anastomosis. This can be facilitated by dividing the inferior mesenteric vein just below the pancreas.

          Microscopic tumor does not spread more than 1 cm beyond the macroscopic tumor border. In contrast discontinuous tumor spread in the mesorectum can go as far as 5 cm anal to the lower tumor border, even though it rarely is found further than 3 cm. This is the reason for the following procedures:

          • Tumor in the rectosigmoid flexure or upper rectum (above 12 cm): The rectum and mesorectum are divided 5 cm anal to the tumor. Avoid coning from the mesorectal fascia to the bowel (the total mesorectum must be resected in all 5 cm). A small remnant of the mesorectum will then remain. In Norway this is called PME (partial mesorectal excision), but this term is not applied internationally and may be misunderstood.
          • Tumor at level 8(9) -12 cm: Bowel and mesorectum is resected 5 cm below the tumor which means TME for all practical purposes.
          • Tumor at 5 to 8-9 cm, planned low anterior resection: Resect all mesorectum to the pelvic floor. Adequate distance on the bowel wall < 1 cm.

          Reconstruction of the bowel tube after low anterior resection for rectal cancer.

          Anastomosis is performed between the descending colon/upper sigmoid and the remaining part of the rectum, if necessary down at the dentate line of the anal canal. A staple instrument is customary applied. An anastomosis at the dentate line can be sutured manually from below.

          Types of anastomoses:

          • End-end colorectal anastomosis, also called straight anastomosis.
          • Side-end colorectal anastomosis without reservoir.
          • Side-end anastomosis with reservoir and a blind loop around 5 cm long. The functional result of this is somewhat better for the first 1-2 years, but the final result is similar to the straight anastomosis. Some consider there is a slightly lower frequency of leakage after a side-end anastomosis, but this has not been clarified. The latter carries the possibility of leakage from the staplers closing the blind loop.
          • End-end coloanal anastomosis, colon is sutured to the dentate line.

          Temporary defunctioning stoma after low anterior resection

          When the anastomosis is 6 cm or below from the anal verge is recommended a temporary defunctioning stoma for 2-3 months until healing of the anastomosis. A defunctioning stoma may also be constructed for anastomoses higher than 6 cm in cases with surgical-technical problems or when a leakage is feared for other reasons in.

          While it is possible that the frequency of leakage is reduced by a temporary stoma, this will at any rate reduce the consequences of a leakage. The pelvic infection is usually milder and a reoperation is unnecessary after a temporary stoma. The leakage problem can often be solved by the application of an “EndoSponge” in the perirectal cavity.

          Equipment

          • Laparotomy- or laparascopic equipment

          Preparation

          Patient preparation:

          • oral bowel emptying.
          • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addition should have oral antibiotics from the day before the surgery.
          • thrombosis prophylaxis with low molecular weight heparin.

          During the surgery it is inserted:

          • epidural catheter for pain management.
          • urinary catheter.
          • naso-gastric tube which is removed by the end of the surgery.

          Implementation

          Step 1 – Trocar insertion and diagnostic laparoscopy

          • Trochar insertion with visiport just to the right of and at the level of umbilicus. A further 12 mm port in the right fossa, one in the midline about 5 cm above the umbilicus, one 5 mm in the left fossa, and one 12 mm suprapubically. Avoid the inferior epigastric vessels and insertion of the caudal trochars too low on the abdomen which may impede the angulation within the abdominal cavity.
          • Examine the primary tumor for perforation and/or infiltration into adjacent organs. Thereafter the liver and the total abdominal cavity is inspected with regard to metastases, peritoneal carsinomatosis (especially the pelvis and the paracolic gutters) and other pathology.

          Step 2 – Release the left transversal colon, left flexure and descending colon

          • The patient in Trendelenburg’s position tilted towards the right. Position the omentum over the liver and put the small bowel package over the midline to the right. If necessary apply an extra trochar suprapubically to expose the Treitz ligament.
          • Open the peritoneum on the posterior abdominal wall medially to the origin of the inferior mesenteric artery after taking down possible adherances at the ligament of Treitz.
          • Continue in the mesocolic plane towards the left flexure and divide the inferior mesenteric vein. Dissect in the mesocolic plane cranially (avoid dissection posterior to the pancreas) and continue anteriorly to the pancreas and into the lesser sac. Be aware that archadic vessels can be located relatively centrally along the colon.
          • Divide adherances along the tail of the pancreas all the way to the lateral abdominal wall. Continue behind the left flexure and descending colon (in front of the pancreas and the left kidney).
          • In front of the colon the gastro-colic ligament is divided just caudally to the gastro-epiploic vessels, divide the splenocolic ligament.
          • Divide the peritoneum laterally to the descending colon along “the white line of Tod”. Carry through till the anterior and dorsal dissections have met and the left flexure and descending colon are completely free.

          Step 3 – Central resection of the inferior mesenteric artery.

          • Lift sigmoid and its mesentery anteriorly and to the left and put it on tension.
          • Incise the peritoneum at the pelvic entrance till the origin of the inferior mesenteric artery in the gutter between the posterior abdominal wall and the sigmoid mesentery.
          • Continue in the posterior mesocolic plane behind the sigmoid mesentery towards the lateral abdominal wall (avoid left ureter).

          A. Cancer of the upper rectum (>12 cm)

          • Dissect the origin of the inferior mesenteric artery at the aorta and divide with hemlock.

          B. Cancer in the middle/lower rectum

          • Dissect the inferior mesenteric artery at the origin of the left colic artery and further along this to the ascending branch of the left colic artery (the inferior mesenteric vein is located close to this crossing).
          • The inferior mesenteric artery is divided with hemlock just distal to the origin of the left colic artery. Possible branches of this artery are divided while the main stem of the left colic and ascending branch are left intact to assure an adequate circulation of the left colon/ sigmoid. Fat with lymph nodes may be dissected off central parts of the superior mesenteric area and removed en-bloc with the lymph nodes at the origin of the left colic artery.
          • During this dissection the main sympathetic nerves must be visualized and retracted posteriorly to avoid injury. Avoid dissection into the parietal fascia in front of the aorta and posterior abdominal wall. If the proper vessel wall is visualised the dissection has been carried on too deeply and the nerve plexus may have been injured.

          Step 4 – Finish the dissection of the sigmoid.

          • Grip the divided mesenteric inferior artery and lift it forward.
          • Continue the dissection in the mesocolic plane till the lateral abdominal wall behind all  the descending colon till the pelvic entrance. Carefully sweep the nerves posteriorly.
          • From the anterior dissect the sigmoid until the left colon, sigmoid and the upper rectum is completely free.

          Step 5 – Total mesorectal excision

          • Extend the peritoneal incision on the posterior abdominal wall (medially) down to rectovesical pouch.
          • Incise the peritoneum transversally in front around 1 cm above the pouch. In female the dissection is performed along the dorsal wall of the vagina.
          • Tips: The proper plane may be difficult to identify on the top of the vagina. With a swab on a stick in the vagina this can be lifted up and forward to simplify the anatomy. In male the wall of the vesicles should be identified and followed on is posterior aspect and further on behind the prostate. It is recommended that the dissection from above is initially stopped 1-2 cm down behind the prostate, the rest can be performed after the posterior dissection.
          • Continue presacrally on to the rectum in the dissection plane developed behind the sigmoid which is the mesorectal plane (Heald’s holy plane”).
          • Dissect in this plane on the outside of the mesorectal fascia from 3-9 o’clock (4-8) as far down as possible. The dissection is then continued from the front and eventually the areas 2-3 and 9-10 are divided.
          • The dissection often has to be performed shifting from dorsally- anteriorly- laterally but the aim should be to go far down behind before continuing in front leaving the lateral dissection lastly. An initial presacral dissection permits the rectum to be lifted up and forward which facilitate the rest of the dissection. The plane is most difficult to identify laterally which is where the nerves are most frequently injured.
          • Fulfilment of the distal dissection.

          Step 6 – Low anterior resection

          • For tumor of the upper rectum the mesorectum is dissected 5 cm anally to the lower border of the tumor.
          • Continue right angled through the mesorectum to the bowel tube at the proper level, thus avoid coning in on the specimen which will render the anal resection margin less than 5 cm.
          • For tumor in the middle/lower rectum the dissection is continued all along to the pelvic floor, and if desired further on to the upper part of the anal canal.
          • Prepare a free bowel wall along the whole circumference. Flush the rectum.
          • Divide the rectum with stapler and try to leave the row of staplers perpendicular on the bowel and close it with one magazine of staplers. More staple shots increase the chance of leakage. Avoid Z-lines.

          Situations can develop when it is impossible to divide the bowel sufficiently far anally. Conversion to an open procedure should then be performed.

          Transanal-TME (ta-TME)

          • The dissection from above is finished at the level of the middle rectum.
          • The dissection from below is performed up to this level.

          Step 7 – Exteriorization of the specimen and division of the oral bowel tube.

          • Make a 6 cm incision transversally above the symphysis (Pfannenstihl incision).
          • Incise the fascia in front of the rectus muscle similarly.
          • Lift both edges of the fascia with Kocker’s forceps and dissect it off the underlying muscle. The dissection must be sharp in the midline.
          • Retract both rectus muscles from the midline.
          • Incise the peritoneum.
          • Apply plastic protection to the edges of the wound and exteriorize the specimen with the central vessels.
          • Divide mesentery and bowel at intended location.
          • Cut with scissors in the vascular arcade close to the bowel to visualize adequate blood circulation in the oral bowel end (adequate systolic blood pressure during the test?). Move further orally on the colon in case of inadequate bleeding.
          • Insert the “hat” of the circular stapler and close with a purse-string suture.
          • Interiorize the colon.
          • Close the abdomen.

          Step 8 – Anastomosis

          • Insert the circular stapler very carefully and perforate the bowel with the pin just in front of or behind the staple row.
          • Attach oral and anal parts of the stapler while controlling the rotation of the bowel. Close the stapler and visually control for possible interposition. Fire the stapler.
          • Test the anastomosis enclosed by water and with air in the rectum.
          • Retract the omentum over the small bowel.

          Step 9 – Laparoscopic control and closure of ports.

          • Repeat inspection of the abdominal cavity for possible iatrogenic injury.
          • Close the ports.


          Follow-up

          • The patient is mobilized in the evening the day of surgery, or possibly the next day.
          • The patient can start to drink and eat carefully on the first postoperative day.
          • A potential wound drainage is removed when there is no longer fresh blood, usually on the first or second postoperative day.
          • The urinary catheter is removed on the fifth postoperative day.
          • The epidural catheter is usually removed on the second or third postoperative day and the patient continues on peroral analgetics.

          Complications

          • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarcion and arrytmias and dysrhythmia may occur. Basilar atelectasis and/or pleural fluid and possibly pneumonia are more common.
          • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare in the absence of anastomotic leakage.
          • Intraabdominal bleeding, inclusive bleeding from anastomosis is relatively rare.
          • After open surgery wound dehiscence and infection in the abdominal wound occur varying degrees, from light superficial infection to abdominal wall abscess.
          • Paralytic ileus is common in the presence of another complication but can also appear without any specific cause.
          • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
          • Port-site hernia occurs after a laparoscopy.
          • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
          • Urinary retention.

          Late complications

          • Ventral hernia in the abdominal wound may occur.
          • Postoperative ileus occurs in about 5%.

          Rectum amputation of rectal cancer (Abdomino-perineal excision -APE)

          General

          The dissection must be performed as a TME (total mesorectal excision) as described by Heald (1). A sharp, visually controlled, dissection is performed in the plane between the visceral and parietal mesocolic/mesorectal fascia.

          Principles for circumferential dissection

          This plane is identified at open operation by primarily freeing the sigmoid from the lateral abdominal wall continuing medially for the whole mesosigmoid till the central part of the posterior abdominal wall. The autonomicnerves and ureter will be left unharmed retroperitoneally on the posterior abdominal wall (behind the parietal fascia, by some called "Told fascia"). Continue in the same plane to the pelvic entrance. After the vessels/lymph nodes are divided in the indicated level, and the colon is divided and can be held up, continue exactly and visually guided dissection in the mesorectal ("holy") plane outside of the mesorectal fascia down in the pelvis. The plane is usually relative easy to define posteriorly and anteriorly because it  follows the rear of vesicles and prostate gland in men, vagina in women. The proper plane should first be identified and followed far down posteriorly, then a bit down anteriorly. The plane is more difficult to define laterally, especially at 10 and 2 o’clock. The dissection here should only be performed after the initial posterior and anterior dissection. Functionally important autonomic nerves are located just on the outside of the proper plane and will be injured by an improper dissection. Dissection on the inside of the proper plane will increase the risk for local recurrence.

          The quality of the resection can be visualized by inspection of the specimen. This should have an intact, even and smooth mesorectal fascia covering the mesorectal fat. In scientific studies it is customary to grade the quality of the specimen and this also ought to be performed in clinical routine and described in the surgical record:

          • Quality A: Intact mesorectal fascia on the whole specimen
          • Quality B: Cuts in the mesorectal fascia, and slightly into the mesorectal fat tissue, none onto the outside of the bowel
          • Quality C: Cuts in the mesorectal fascia/fat tissue onto the rectal wall

          The quality of the dissection can further be estimated by the integrity of the Toldt´s fascia (parietal mesocolic fascia) on the posterior abdominal/pelvic wall, this should be intact.

          Distal dissection of rectum amputation (APE)

          In distal parts of the rectum the mesorectal fat tissue is very thin, and if standard TME to the pelvic floor is performed, that is, dissection close to the mesorectal fascia distally, there will be a very short distance from the tumor to the resection margin, even if there is only a T2 or an early T3 tumor. Similarly, the margin from the metastatic lymph nodes may become very short. Therefore, the dissection should not be performed close to the distal part of the mesorectal fascia during an amputation, the dissection should rather be finished from above several centimeters above the levator plane.

          There are three main types of rectum amputation (APE):

          • Intersphincteric  APE 
          • Extralevator abdominoperineal excision (ELAPE) (“cylindrical excision”)
          • Ischio-anal APE

          Intersphincteric  APE

              Intersphincteric APE is not suitable for distal cancers with short margin to the distal part of the mesorectal fascia The method is suitable for tumors treatable with low anterior resection, but where an anastomosis cannot be performed, either because of the high risk of leakage in patient's which cannot tolerate serious complications or there is an incontinence present, that will cause a poor functional  outcome.

          A dissection is performed on the mesorectal fascia to the pelvic floor, and the distal rectum is closed to avoid spillage. A perineal procedure, including cleaning of the analcanal is performed. The skin in the intersphincteric hollow is incised all around and the anal opening closes. A Lone Star retractor is then inserted  and dissection is performed upwards in the intersphincteric plane to the level above puborectalis  to the pelvic cavity, until anus and distal rectum are free. Remove the specimen. The defect in the skin- and pelvic floor is small and is closed.

          Extralevator abdominoperineal excision (ELAPE) (“cylindrical excision”)

          ELAPE is recommended when the distal tumor is growing near the mesorectal fascia/sphincter/levator. The procedure is relevant when an ultralow anterior resection or an intersphincteric resection would cause a risk for none or a very short distance to the mesorectal fascia, and also increase the risk of bowel perforation.

          The dissection from above must stop before reaching the pelvic floor, it should only be performed down to the sacrococcygeal transition posteriorly; until distal to the inferior hypogastric plexus anterolaterally; to just under the seminal vesicles in men and the cervix uteri in women.

          Ususally, it is preferred to perform the perineal part of the procedure in the prone position, after construction of the sigmoid colostomy. The patient is lying with the upper body slightly downwards, with the hip kinked 30-40 degrees and the legs spread out.

          After the patient is turned around and the area is cleaned, a purse-string suture is used to close the anus. A boat shaped insicion is performed around anus (there is no need to make it wide), and the dissection is performed just outside of sphincter externus and up underneath the levator muscle. The dissection is then performed laterally along the underside of levator  out to the lateral pelvic wall so that the division of the muscles can be performed completely out on the sides. The integrity of the distal mesorectum, which is covered by a cuff of muscle/fat tissue, will in this way be preserved. The coccyx is resected to improve access to the pelvis and the pelvic cavity is entered right in the front edge of the bone and the mesorectal fascia is identified. This is difficult, and to avoid damage on the mesorectal fascia and fat pad, the procedure requires great attention. Inside the pelvic cavity, it is important to ensure that the dissection is performed in the correct direction (along the sacrum).

          The levator muscles must be divided properly out on the sides, from behind and in a forward direction. When both sides are loose, gently pull the oral bowel end out through the opening and twist the specimen. How early in the progress this may be performed depends on the thickness of the tumor/mesorectum and the available opening. There must not be used any force when the bowel is twisted down and out. When this is performed the rectum is still located in the anterior structures, in which there are now excellent visibility. The anterior dissection must always be performed with great caution and under continuous control by following the plane against prostate/vagina and avoiding damage of these and the urethtra distally from prostate. The dissection anteriorly, on the side and posteriorly should be performed incrementally, and the specimen should be held in different directions for control of a correct dissection plane. If the tumor/lymph nodes some places are threatening the mesorectal fascia, it may be necessary to dissect outside the plane to achieve R0 resection (extended TME).

          Anteriorly the dissection plane for standard TME and cylindrical APE will be identical, but on the sides the dissection plane is much further out. Withdrawing of a complete cylinder (the levators are divided as far out as possible all around) is leading to a large defect in the pelvic floor which cannot be closed, this may cause problems with the healing and later on perineal hernia. Therefore, the cylindrical excision may in some cases be adapted to tumor growth. For example, if the tumor only threatens the resection margins on the left side, removal of a complete cylinder on the right side is not nessesary.

          Ischio-anal APE

          If tumor is infiltrating or perforating the pelvic/levator (may be associated with abscess under levator, or fistula into the rectum/skin) an extended excision of skin and ischiorectal tissue must be performed to ensure R0 resection.

          Principles for regional lymph node dissection

          • For cancer in the rectosigmoid flexure the vessels/lymph nodes should be resected as in sigmoid cancer, which means at the origin of the inferior mesenteric artery at the aorta.
          • For cancer in the upper rectum it is probably adequate to resect the inferior mesenteric artery just distal to the origin of the left colic artery with removal of the local lymph nodes. Fat and lymph nodes in the apical station may be removed even if the artery is resected distal to the left colic artery.
          • For cancer in the middle and lower rectum the vessels and lymph nodes are resected just distally to the origin of the left colic artery.

          Reconstruction of the pelvic floor/perineum  after cylindrical rectal amputation

          After a cylindrical rectum amputation a large defect arises in the pelvic floor muscles. This cannot be closed with simple sutures. There is also a defect in subcutaneous fat and in skin which can be closed, but tensioning must be expected. There are often problems with the healing of the perineal wound, both because it is an unclean area where infection easily can occur and because there is a tensioning of tissue after closing. In patients who have undergone preoperative radiotherapy, the problems are bigger and occur more frequently.

          There are several alternative methods to close the defect in the pelvic floor after rectal amputation:

          • The pelvic floor is adapted in the best possible way with simple sutures.
          • A net equivalent to what is used in hernia operations is sewn into the defect in the levator plate.
          • Musculo-cutaneous swing flap with the rectus muscle from the abdominal wall. Vertical rectus abdominus plasty (VRAM). Rectus musculature with skin are dissected with the patient in supine position. The blood supply to the flap have to be ensured. The flap is pivoted around its own distal anchoring down in the small pelvis.The abdomen is closed and the patient is moved to prone position. The VRAM flap is sewn to the edges of the remaining levator musculature. The skin on the flap is sewn on the perineal skin.
          • Musculo-cutaneous swing flap with gluteus maximus muscle.

          There are advantages and disadvantages with the methods, and there are different views of what is best. The larger defects the better indication to use swing flap. When performing swing flap, plastic surgical expertise must be present.

          Postoperative complications are wound infection, infection of the small pelvis, slow healing, persistent sinus, necrosis of the swing flaps and perineal hernia.

          Equipment

          • Laparotomy- or laparascopic equipment

          Preparation

          Patient preparation:

          • oral bowel emptying.
          • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addition should have oral antibiotics from the day before the surgery.
          • thrombosis prophylaxis with low molecular weight heparin.

          During the surgery it is inserted:

          • epidural catheter for pain management.
          • urinary catheter.
          • naso-gastric tube which is removed by the end of the surgery.

          Implementation

          Step 1 – Trocar insertion and diagnostic laparoscopy

          • Trochar insertion with visiport just to the right of and at the level of umbilicus. A further 12 mm port in the right fossa, one in the midline about 5 cm above the umbilicus, one 5 mm in the left fossa, and one 12 mm suprapubically. Avoid the inferior epigastric vessels and insertion of the caudal trochars too low on the abdomen which may impede the angulation within the abdominal cavity.
          • Examine the primary tumor for perforation and/or infiltration into adjacent organs. Thereafter the liver and the total abdominal cavity is inspected with regard to metastases, peritoneal carsinomatosis (especially the pelvis and the paracolic gutters) and other pathology.

          Step 2 – Release the left transversal colon, left flexure and descending colon

          • The patient in Trendelenburg’s position tilted towards the right. Position the omentum over the liver and put the small bowel package over the midline to the right. If necessary apply an extra trochar suprapubically to expose the Treitz ligament.
          • Open the peritoneum on the posterior abdominal wall medially to the origin of the inferior mesenteric artery after taking down possible adherances at the ligament of Treitz.
          • Continue in the mesocolic plane towards the left flexure and divide the inferior mesenteric vein. Dissect in the mesocolic plane cranially (avoid dissection posterior to the pancreas) and continue anteriorly to the pancreas and into the lesser sac. Be aware that archadic vessels can be located relatively centrally along the colon.
          • Divide adherances along the tail of the pancreas all the way to the lateral abdominal wall. Continue behind the left flexure and descending colon (in front of the pancreas and the left kidney).
          • In front of the colon the gastro-colic ligament is divided just caudally to the gastro-epiploic vessels, divide the splenocolic ligament.
          • Divide the peritoneum laterally to the descending colon along “the white line of Tod”. Carry through till the anterior and dorsal dissections have met and the left flexure and descending colon are completely free.

          Step 3 – Central resection of the inferior mesenteric artery

          • Lift sigmoid and its mesentery anteriorly and to the left and put it on tension.
          • Incise the peritoneum at the pelvic entrance till the origin of the inferior mesenteric artery in the gutter between the posterior abdominal wall and the sigmoid mesentery.
          • Continue in the posterior mesocolic plane behind the sigmoid mesentery towards the lateral abdominal wall (avoid left ureter).

          A. Cancer of the upper rectum (>12 cm)

          • Dissect the origin of the inferior mesenteric artery at the aorta and divide with hemlock.

          B. Cancer in the middle/lower rectum

          • Dissect the inferior mesenteric artery at the origin of the left colic artery and further along this to the ascending branch of the left colic artery (the inferior mesenteric vein is located close to this crossing).
          • The inferior mesenteric artery is divided with hemlock just distal to the origin of the left colic artery. Possible branches of this artery are divided while the main stem of the left colic and ascending branch are left intact to assure an adequate circulation of the left colon/ sigmoid. Fat with lymph nodes may be dissected off central parts of the superior mesenteric area and removed en-bloc with the lymph nodes at the origin of the left colic artery.
          • During this dissection the main sympathetic nerves must be visualized and retracted posteriorly to avoid injury. Avoid dissection into the parietal fascia in front of the aorta and posterior abdominal wall. If the proper vessel wall is visualised the dissection has been carried on too deeply and the nerve plexus may have been injured.

          Step 4 – Finish the dissection of the sigmoid

          • Grip the divided mesenteric inferior artery and lift it forward.
          • Continue the dissection in the mesocolic plane till the lateral abdominal wall behind all  the descending colon till the pelvic entrance. Carefully sweep the nerves posteriorly.
          • From the anterior dissect the sigmoid until the left colon, sigmoid and the upper rectum is completely free.

          Step 5 – Total mesorectal excision

          • Extend the peritoneal incision on the posterior abdominal wall (medially) down to rectovesical pouch.
          • Incise the peritoneum transversally in front around 1 cm above the pouch. In female the dissection is performed along the dorsal wall of the vagina.
          • Tips: The proper plane may be difficult to identify on the top of the vagina. With a swab on a stick in the vagina this can be lifted up and forward to simplify the anatomy. In male the wall of the vesicles should be identified and followed on is posterior aspect and further on behind the prostate. It is recommended that the dissection from above is initially stopped 1-2 cm down behind the prostate, the rest can be performed after the posterior dissection.
          • Continue presacrally on to the rectum in the dissection plane developed behind the sigmoid which is the mesorectal plane (Heald’s holy plane”).
          • Dissect in this plane on the outside of the mesorectal fascia from 3-9 o’clock (4-8) as far down as possible. The dissection is then continued from the front and eventually the areas 2-3 and 9-10 are divided.
          • The dissection often has to be performed shifting from dorsally- anteriorly- laterally but the aim should be to go far down behind before continuing in front leaving the lateral dissection lastly. An initial presacral dissection permits the rectum to be lifted up and forward which facilitate the rest of the dissection. The plane is most difficult to identify laterally which is where the nerves are most frequently injured.

          Step 6 – Performe sigmoideostomy in the correct area (selected preoperatively)

          Step 7 – Laparoscopic control and closure of port

          • Repeat inspection of the abdominal cavity for possible iatrogenic injury.
          • Close the ports.

          Follow-up

          • The patient is mobilized in the evening the day of surgery, or possibly the next day.
          • The patient can start to drink and eat carefully on the first postoperative day.
          • A potential wound drainage is removed when there is no longer fresh blood, usually on the first or second postoperative day.
          • The urinary catheter is removed on the fifth postoperative day.
          • The epidural catheter is usually removed on the second or third postoperative day and the patient continues on peroral analgetics.

          Complications

          • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarcion and arrytmias and dysrhythmia may occur. Basilar atelectasis and/or pleural fluid and possibly pneumonia are more common.
          • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare in the absence of anastomotic leakage.
          • Intraabdominal bleeding, inclusive bleeding from anastomosis is relatively rare.
          • After open surgery wound dehiscence and infection in the abdominal wound occur varying degrees, from light superficial infection to abdominal wall abscess.
          • Paralytic ileus is common in the presence of another complication but can also appear without any specific cause.
          • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
          • Port-site hernia occurs after a laparoscopy.
          • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
          • Urinary retention.

          Late complications

          • Ventral hernia in the abdominal wound may occur.
          • Postoperative ileus occurs in about 5%.
          Extralevatoric APEIntersfincteric amputationIschioanal APEConventional APE

          Rectum amputation with swing flap

          General

          A rectum amputation, or abdomino perineal resection (APR), is performed when tumor is situated so low that the sphincter muscle or pelvic floor is infiltrated. In a rectum amputation, the rectum, as well as the anal canal and some of the pelvic floor muscles are removed. The sigmoideum is then used to make a stoma.  

          If the distance to the tumor is short, an extended rectum amputation (also called a cylindrical rectum amputation) is performed. More of the pelvic floor is removed for this procedure. The defect in the pelvic floor or perianal skin must often be reconstructed with a net or swing flap consisting of muscle and skin. At the Radium Hospital, this is done in collaboration with a plastic surgeon. 

          There is a higher frequency of local recurrence after a rectum amputation than a after a low anterior resection. The cause of this is somewhat unclear. In the lower part of the rectum, it is very narrow or there is no mesorectal fat. The tumor will therefore quickly infiltrate the pelvic floor muscle if infiltrating the rectal wall. If the infiltration is not macroscopic, this dissection can easily occur in the layer between the rectum and pelvic floor. The tumor may then be perforated and cancer cells released. By stopping the resection toward the pelvic floor from the abdomen earlier, this can be avoided. A cylindrical dissection must be performed in all cases for large, low tumors (T3/T4).  

          Previously, rectum amputations were performed on 50-60% of rectal cancer cases. After introduction of the total mesorectal resection (TME), the frequency has been reduced to 20-30%. At some foreign treatment centers, about 90% are anastomosized. The percentage depends on how many are irradiated before surgery and whether the most advanced tumors are treated at the hospital or not. It is somewhat unclear how many patients have stool incontinence after very low surgery. Many surgeons therefore prefer a rectum amputation or Hartmann's operation if anal function is reduced. 

           

          During the reconstruction phase of the operation, the stoma is made.

          Indications

          • Localized rectal cancer.
          • Tumor situated very low and infiltrating the pelvic floor muscle such that the pelvic floor muscle must be removed. 

          Goal

          • Curation
          • Palliation in patients with relatively long expected survival time despite distant metastases.

          Preparation

          • The patient is prepared for a permanent stoma and its location is marked on the skin.
          • Bowel emptying is not necessary if anastomosis is ruled out from the start.
          • Thrombosis prophylaxis
          • Antibiotic prophylaxis 
          • Epidural catheter is installed for postoperative pain treatment.
          • A bladder catheter is inserted (Foley catheter).
          • The patient lies horizontal on the operation table. When the perineal phase will be performed, the patient is turned over to his/her abdomen and the hips are elevated. 
          • The operation is carried out under general anesthesia.

          Implementation

          Dissection

          Abdominal access

          • The sigmoid colon is mobilized from any adhesions so that a tension-free stoma can be constructed.
          • Sharp mesorectal dissection is performed.
          • The dissection from above is stopped at the base of the coccygeus, at the attachment of the levator ani muscle on the internal lateral obturator muscle, and as far down behind the vagina/prostate as feasible.
          • Coccygeus is separated from the sacrum.
          • A sigmoideostomy is made.
          • The musculo-cutaneous swing flap (vertical rectus abdominus (VRAM)) is dissected and turned into the pelvis.
          • A large compress is placed in front of the sacrum to hold the bowels out of the pelvis and the flap in place.
          • A vacuum drain is placed in the pelvis.
          • The abdomen is closed.
          • The patient is turned to the prone position.

          Perianal access

          • The anal opening is closed with a purse-string suture and a perianal incision is made in the skin extending up over the coccygeus.
          • The dissection goes in the ischiorectal tissue dorsally to the base of the coccygeus and laterally to the attached internal obturator muscle.
          • The levator ani muscle is followed from the coccygeus laterally and loosened from the internal obturator muscle.
          • The rectum is mobilized and the vesicles/prostate/vagina are identified and dissected from the rectum.
          • The urethral catheter is palpated in men and the urethra is avoided.
          • The specimen is removed.

          Reconstruction

          • VRAM flap (Vertical rectal abdominal muscle flap) is sutured laterally to the rest of the pelvic floor muscles and in the defect in the perineal skin.
          • Vacuum drain is placed deep to the VRAM flap.

          Follow-up

          • The patient may drink and eat on the first postoperative day.
          • The epidural catheter is removed usually on the 2nd-3rd day and the patient obtains an oral analgesic.
          • The abdominal drain is removed when there is no longer fresh blood, usually on the 2nd-3rd day. The swing flap drain should be removed  when the draining volume is less than 200 ml/day.
          • The bladder catheter is kept until the bladder empties spontaneously to prevent a large bladder from  pressing on the swing flap thereby reducing its circulation and possible necrosis of the flap.
          • Due to the swing flap, the patient should stay in bed for one week and avoid lying in the supine position.
          • The patient is usually discharged after 3 weeks.

          Complications from surgery

          • For rectal amputations, the postoperative mortality rate is 0-3%.
          • Cardiopulmonary complications depend on the patient's general health status, the duration and extensiveness of surgery. 
          • Postoperative ileus occurs in about 5 %.
          • Ventral hernias in the abdominal inscision occur relatively frequently.
          • Separation of the musculocutanous flap from the skin
          • Necrosis of the musculocutaneous swing flap may occur.

          Damage to the autonomic nerves in the pelvis can cause:

          • bladder paralysis—often temporary
          • erection and ejaculation problems
          • vaginal dryness 

           

          Cylindrical rectum amputation with swing flap.Cylindrical rectum amputation with swing flap.Cylindrical rectum amputation with swing flap.Cylindrical rectum amputation with swing flap.

          Hartmann's Operation of colorectal cancer

          General

          Hartmann's operation is applied when the conditions are not suitable for anastomosis and simultaneously when it is not necessary to remove the pelvic floor with the anal canal. Hartmann's operation is also performed if the patient has poor anal sphincter function or if the patient's general status is too poor to tolerate a possible anastomosis leakage.

          The procedure is rarely used in localized primary cancer, and is often of a secondary choice.

          Indications 

          • cancer in the rectum
          • cancer in the sigmoideum

          Goals

          • Curation
          • Avoid damage to the autonomic pelvic nerves
          • Reduce the operation time by not removing the anal canal
          • Avoid delayed healing in the perineum as in a rectal amputation
          • Palliation if the patient has a long expected survival despite metastases

          Equipment

          • Laparotomy tray
          • Staple instrument: cross stapling  /closing/cutting
          • Surgery table with adjustable leg supports

          Preparation

          • Placement of the stoma is marked on the skin.
          • Patients in which an anastomosis is planned should have a thorough bowel emptying procedure.
          • Thrombosis prophylaxis
          • Antibiotic prophylaxis
          • Epidural catheter is inserted for postoperative pain treatment.
          • A bladder catheter is inserted.
          • The patient lies horizontally on the operation table with legs supported to be lifted easily if an anastomosis is to be performed.
          • The operation is carried out under general anesthesia. 

          Implementation

          Dissection

          The resection is performed similar to a mesorectal excision.

          • A mid-line incision from the symphysis is normally extended to the right of the navel.
          • The sigmoid colon is released laterally.
          • The inferior mesenteric vessels are identified and divided distal to the left colic vessels.
          • The upper resection level is identified and the bowel is divided with a staple/dividing instrument.
          • The peritoneum is split on both sides of the rectum. The perimesorectal plane is followed dorsallyi and laterally. In front the plane is behind the vesicles and prostate/vagina. The dissection is followed all the way to the pelvic floor if the tumor is less than 12 cm from the anal verge, or 5 cm below the tumor if it is higher than 12 cm.
          • The sympathetic hypogastric nerve is identified if possible on the pelvic wall.
          • The parasympathetic pelvic plexus is often difficult to identify on the pelvic wall.
          • If possible, the bowel is closed at least 1 cm below the tumor.
          • The distal end is rinsed with distilled water.
          • A new row of staples is set at the desired level and the bowel is split between the rows of staples.

          Reconstruction

          • Sigmoideostomy is made in the marked area of the left rectal sheath.
          • Vacuum drain is put in the pelvis.
          • The abdomen is closed.

          Follow-up

          • The patient may be mobilized as early as possible.
          • The patient may begin to drink and eat on the first postoperative day.
          • The drain is removed when there is no longer fresh blood - usually on the 2nd–3rd day.
          • The bladder catheter is removed as soon as possible. Because the surgery often causes temporary bladder paralysis it may have to stay for about one week.  
          • The epidural catheter is removed usually after 2–3 days and the patient obtains an oral analgesic.

          Complications from surgery

          Early

          • Cardiopulmonary complications depend on patient general health status, the duration of the surgery, and extent.
          • Complications from stoma may occur.
          • Possible infection in the pelvis can perforate the rectal stump, and empty through the stump.

          Damage to the autonomous nerves in the pelvis may cause:

          • bladder paralysis—often temporary
          • erection and ejaculation problems
          • vaginal dryness

          Delayed

          • Ventral hernia in the abdominal incision and peristomal hernias may occur.
          • Postoperative ileus occurs in about 5% regardless of radiation treatment.
          • Stomal prolapse occurs relatively rarely.

           

          Hartmann's operationHartmann's operationHartmann's operationHartmann operation
          Hartmann's operation

          Stoma

          General

          Intestinal stoma is often required during treatment of rectal cancer and sometimes for colon cancer. The stoma is either permanent or temporary. Stoma is also constructed for temporary relief of distal anastomosis or ileus.

          Permanent stoma is prepared when the rectum is removed or when there is an inoperable tumor or ileus due to extreme adherences. Preferably, it is placed as close to the anus as possible to provide the best possible reabsorption of nutrition and fluid.

          The procedure may be performed by laparoscopy.

          A stoma can have with one or two openings. The type of stoma depends on the purpose of the stoma and anatomical conditions in the abdomen.

          End stoma 

          The colon is divided and the oral end is brought out. The end stoma is easier to handle and is better looking than a loop stoma. The end stoma is usually performed for permanent stomas and for relief of fistulas.

          Loop stoma 

          The colon is not divided but is pulled out like a loop through the abdominal wall. An opening is made in the top of the loop. The stoma has two openings: one oral and one aboral. The stoma can be prepared in two ways:

          • symmetrical—an opening is made on the top of the extracted "backwards U." The ingoing and outgoing openings of the bowel looks similar. Symmetric loop stoma are usually performed for colostomy  .
          • asymmetrical—the oral part of the bowel is brought forward and empties easier into the bag while the aboral part of the bowel is at the skin level and the opening is small. Asymmetric loop stoma is usually created for an ileostomy .

          Sigmoid colostomy 

          Sigmoid colostomy is the most common form of colostomy. The stoma is installed if it is not technically possible or sensible to anastomose the colon to the rectum/anal canal. It is then constructed as a permanent end stoma. This is done in 15-30% of patients with rectal cancer.

          Indications

          Permanent:

          • for rectal amputation
          • to avoid permanent incontinence of poor anal sphincter function (Hartmann's operation)
          • to relieve an inoperable fistula anally from the stoma

          Temporary:

          • for preoperative radiation
          • relief of rectal ileus

          Sigmoid colostomies are easy to maintain. The stools usually has a normal consistency and causes little irritation to the skin.

          Transverse colostomy 

          The transverse colon is brought out in the right rectus muscle. This is a loop stoma and is often temporary. It is often difficult to maintain because the stoma is voluminous and the feces is thin and foul-smelling. This type of stoma is associated with more complications than a sigmoidostomy. As a temporary stoma it has similar frequency of complications as ileostomas.

          There is a risk that the bowel content may pass into the distal opening with an incomplete relief of stools.

          Indications

          • relieve stenosis in the left colon
          • relieve low anastomosis or rectum resection
          • allow rinsing of the left colon through the stoma in limited anastomosis leakage

          Ileostomy

          The ileum is brought out  20-30 cm from the cecum and preferably in the right rectus muscle as an asymmetrical loop stoma. It is relatively simple to construct but can be difficult to maintain due to thin fecal content. The longer nipple will help avoiding damage to the skin.

          Indications

          • protect anastomoses after rectosigmoid resection
          • relieve bowel obstruction
          • relieve preoperative radiation of stenosis due to colorectal cancer
          • relieve fistula

          Indications for stomas

          • Cancer in the rectum (rectum amputation, Hartmann)
          • Cancer in the colon

          Goals

          • Facilitate output of bowel contents
          • Relieve the bowel/stenosis/fistula

          Equipment

          • Laparotomy tray and possibly laparoscopy equipment.
          • A device to place under the loop.

          Preparation

          The patient should be prepared for:
          • anatomical and physiological changes following the operation
          • what a stoma involves
          • stoma equipment and how it functions
          • the stoma is edematous the first weeks after the operation and that it will normalize

          Stoma marking

          The patient is informed of the purpose of the stoma marking. The goal is to find appropriate placement in order for the patient to maintain the stoma.

          It is important to see the patient, lying, sitting, standing, and during movement. By seeing the abdomen in different positions, the abdomen's shape is emphasized such that individual considerations are taken during marking. The patient should be able to address their own wishes and desires.

          Factors influencing the location

          • the stoma should be visible to the patient.
          • the stoma should be placed within the rectus muscle
          • the stoma disc and stoma should not come in conflict with skin folds, groin, hollow areas, iliac crest, scars, hernias, the navel, or straps for prosthesis or binder
          • the stoma should not hamper the clothing
          • choice of stoma type

          Marking:

          • The rectus muscle is identified on the side where the stoma will be placed
          • The appropriate stoma location is adjusted by using a piece of tape which is moved about on the abdomen when the patient lies down, sits, and stands.
          • The patient must be offered to walk with the disc and bag to check that the stoma marking is optimal.
          • Final marking for placement is done with a waterproof marker.

          Implementation

          • When the stoma is not brought out through the abdominal inscision but through a separate hole in the abdominal wall it will be easier to handle. For transversostomy: an incision is made in the right rectus muscle and the omentum is dissected off the attachment to the relevant part of the colon. It may be difficult to obtain sufficient length of the bowel without damaging the vessel supply if the abdominal wall is thick. For an ileostomy, this is more simple.
          • The least amount of skin is removed if the stoma is not brought out through the abdominal inscision.
          • The bowel is pulled out as a backwards "U" and is not divided.
          • The bowel is sutured to the peritoneum.
          • The bowel is sutured to the anterior fascia.
          • A tube or skin bridge is placed under the loop at the skin level to prevent the bowel from retracting.
          • The bowel lumen is opened at the top and the bowel wall is everted and sutured to the skin.
          • For a section in the right rectus chain, the stoma is placed out through a separate incision to facilitate stoma hygiene.
          • Colostomy should preferably be pulled 1-2 cm out over the skin level. Ileostomy: 2-3 cm.

          End sigmoid colostomy:

          • A mid-line incision to the right of the navel is made.
          • The bowel is divided with a closing-dividing stapler.
          • The bowel is mobilized by adequate division of the vessels without damaging the vessel archade to permit the bowel to be pulled out through the skin without tightening.
          • In the abdominal wall, the peritoneum and posterior fascia leaf are split.
          • The musculature is split length-wise and as much as necessary transversally.
          • The anterior fascia leaf is split in a cross.
          • A skin cylinder with underlying fatty tissue is removed up to the fascia.
          • The extracted bowel opening is sutured to the fascia and everted with sutures  in the bowel tube, mucosa  and skin.

          Follow-up

          The very first stoma changes after an operation should be performed on the third postoperative day. If the stoma bandage leaks, this must be changed earlier. The change should be carried out by a stoma nurse/nurse while the patient is in the supine position. The stoma is observed for possible infection, necrotizing mucosa or abdominal wall, loosening of sutures, and for leakage of air and bowel content. Bag inflation is a signs of bowel activity. It is appropriate to use a colorless, drainable bag in the first period since the bowel content is thinner in the beginning. If a bag with a filter is used, the filter should be covered.

          As soon as the patient is ready for it, the patient is trained for stoma changing/cleaning. Training should occur daily until the patient has mastered it.

          Transverse colostomies and ileostomies can be closed after about six weeks. For closing of ileostomy, there is a higher chance of postoperative ileus and possibly also for bowel leakage than with colostomy.

          For Hartmann's operation, the goal in some instances is to perform a re-anastomosis of the bowels and to avoid permanent stoma.

          Complications of stoma

          Early

          • Infection in the subcutaneous tissues occurs relatively often and more commonly with obesity.
          • Necrotizing of mucosa or the entire abdominal wall occurs more frequently in patients with a thick subcutaneous fat layer.
          • Loosening of eversion sutures along the edge occurs relatively frequently.
          • Retraction of stoma to the skin level or under occurs relatively rarely, but more frequently for loop colostomy. Retraction can cause overflow to the disconnected bowel. This is especially unfortunate in fistula relief.
          • Colo-cutaneous/ileo-cutaneous fistulas occur rarely.

          Delayed

          • Peristomal hernia is a complication where the stoma bulges out like lump on the skin. This can make attachment of the stoma bag more difficult and the stoma may have to be moved.
          • Stenosis in the stoma opening occurs relatively rarely. It occurs if the bowel opening is not adequately inverted or if the tip of the stoma necrotizes down to or under the skin level.
          • Retraction of the stoma down to or under the skin level occurs relatively rarely.
          • Prolapse of stoma is a relatively rare complication where the bowel turns itself 10 cm or more out through the stoma opening. This happens most often in transverse colostomy stomas. The herniation can cause increased pressure to the bowel vessels through the abdominal wall and possible cause bowel necrosis. This complication can be treated conservatively but may relapse.
          Stoma placementStoma placementStoma placementStoma placement
          Stoma placementStoma placementStoma placement

          We are updating drug therapy of cancer in the colon and rectum

          Oncolex is an online reference tool where health professionals can retrieve updated information about diagnostics, treatment and follow-up care of cancer

          The content is written by our editorial staff, in collaboration with medical professionals, specialised in the various types of cancer.

          The information about drog therapy is currently under professional evaluation and will be available again as soon as the work has been completed.

          We are updating radiation therapy of cancer in the colon and rectum

          Oncolex is an online reference tool where health professionals can retrieve updated information about diagnostics, treatment and follow-up care of cancer.

          The content is written by our editorial staff, in collaboration with medical professionals, specialised in the various types of cancer.

          The information about radiation therapy of cancer in the colon and rectum is currently under professional evaluation and will be available again as soon as the work has been completed.

          Complication treatment of cancer in the colon and rectum

          Surgery, medicinal treatment, and radiation therapy cause side effects to a varying degree.

          Supportive care may be necessary for the patient to complete treatment and to gain the full effect of planned treatment.

          Supportive care may also be given to reduce side effects and to improve the patient`s quality of life during and after treatment.

          PROSEDYRER

          Treatment of Nausea Induced by Chemotherapy

          General

          The majorities of chemotherapy drugs are emetic to varying degrees and may cause nausea and vomiting. Today, there are efficient antiemetic drugs that can significantly reduce the side effects.

          Other factors that can aggravate or prolong the presence of nausea and vomiting are: pain, anxiety, electrolyte disturbances, constipation, dyspepsia, and ulcers.

          There is a distinction between acute nausea, which occurs within the first 24 hours, and late nausea, which occurs later than 24 hours after the treatment.

          Acute nausea can be effectively treated with 5HT3-antagonists (ondansetron, tropisetron, palonosetron), and possibly combined with steroids. Dopamine antagonists (metoklopramid, metopimazine) also have some effect on acute nausea. If this treatment is not effective, it may be improved with aprepitant.

          If standard prophylaxis and treatment of nausea is not satisfactory, other nausea regimens should be tried.

          Indication

          • Nausea induced by chemotherapy drugs.

          Goal

          • Prevention and treatment of nausea and vomiting.

          Definitions

          Chemotherapies according to emetic potential

          High emetogenicity   

          Group 1

          Moderate emetogenicity   

           Group 2

          Low/minimal emetogenicity

          Group 3

          All cisplatin-containing regimens (CiFu, GemCis, BEP, TIP, VIP, PV, AP, EDP, DHAP, ECX, weekly dose cisplatin, and others) BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosfamide, vincristine, prokarbazine, prednisolone)
          Doxorubicin/epirubicine weekly dose
          Doxorubicin/ifosfamide Bendamustine
          Docetaxel
          FEC-60 og FEC-100
          (fluorouracil, epirubicin, cyklophosfamide)
          Carboplatin
          ENAP (etoposide, mitoxsantrone, cytarabine, prednisolone)
          ABVD (doxorubicin, bleomycin, vinblastine, dakarbazine Carboplatin/pemetrexed
          FLv (fluorouracil)
          FOLFIRINOX
          Carboplatin/vinorelbine
          FuMi (fluorouracil, mitomycin)

          CHOP (cyclophosfamide, doxorubicin, vincristine, prednisolone)
          Gemcitabine

          CHOEP (cyclophosfamide, doxorubicin, vincristine, etoposide, prednisolone)
          Methotrexate weekly dose
             Dakarbazine
          Navelbine
                ECO/ACO (epirubicin/doxorubicin, cyclophosfamide, vincristine)
          Paclitaxel
                 EOX (epirubicin, oxaliplatin, capecitabine)
          Pemetrexed
                EPOCH-F (etoposide, prednisolone, vincristine, cyclofosfamide, doxorubicin, fludarabine)

              EPOCH-F (etoposide, prednisolone, vincristine, cyclophosfamide, doxorubicin, fludarabine)
           
              FLIRI (fluorouracil, irinotecan)
           
              FLOX (fluorouracil, oxaliplatin)    
             Gemcitabine/carboplatin      
             HD-Cytarabine
             
              HD-Methotrexate    
            IGEV (ifosfamide, gemcitabine, vinorelbine)
            
             IME (ifosfamide, methotreksate, etoposide)  
             Irinotecan  
             Streptozocin  
             Vorphase (cyclophosfamide)
           

          References

          1. Lehne G, Melien Ø, Bjordal K, Aas N, Mella O. Kvalme og oppkast ved cytostatikabehandling i: Dahl O, Christoffersen T, Kvaløy S, Baksaas. Cytostatic Medication cancer treatment. 7. edition. Oslo. Department of Pharmacotherapeutics and The Norwegian Cancer Society, 2009, p 119-130.

          Preparation

          Nausea regimens are selected according to the emetogenicity of the relevant drugs.

          • Inform about the risk for and treatment of nausea. 
          • In the event of anxiety or conditional nausea, give tranquilizers if necessary.

          Implementation

          • Start with an optimal antiemetic regimen starting with the first cycle of chemotherapy in order to counteract the amplification of the nausea that often occurs with a new treatment.
          • Start the oral antiemetic regimen 1-2 hours before chemotherapy and approx. 15-30 minutes before an intravenous injection.
          • If the patient is already nauseous, the medication should be administered parenterally or rectally.

          Antiemetic regimens

          Mildly emetic chemotherapy

          • Metoclopramide 10 mg is given intravenously before treatment with cytostatic agents.
          • Metoclopramide 10 mg is given orally uptil 3 times.

          Moderately emetic chemotherapy

          Ondansetron 8 mg orally 2 x daily. In the event of nausea before treatment, give ondansetron intravenously. If this has little effect, try ondansetron 8 mg x 3 or change to a 5HT3-antagonist, for example, tropisetron 5 mg orally/intravenously or palonosetron 250 µg intravenously.

          Highly emetic chemotherapy, or if other treatment does not help

          For highly emetic chemotherapy drugs, or if other treatment is not adequate, a 5HT3-antagonist can be given orally or intravenously. It should be combined with dexamethasone 8-16 mg intravenously ½-1 hour before treatment, and further, 8 mg x 2 intravenously or orally on the first day.

          In addition, dopamine antagonists may be given, for example, metoclopramide 10 mg x 3.

          In some cases, traditional nausea treatment is not sufficient. In this case, the patient can be treated with aprepitant. Aprepitant is used for highly emetic regimens and for patients where the usual antiemetic treatment has failed during moderate emetogenic treatment. Aprepitant is given orally 1 hour before chemotherapy and is combined with dexamethasone and 5HT3-antagonists:  125 mg capsules orally on day 1, then 80 mg orally on days 2-5, depending on the duration of the treatment. Aprepitant can enhance the effect of taxane and etoposide, as well as vinorelbine, and can reduce the effect of warfarin.

          The regimen is repeated daily if highly emetic treatment is given over a number of days.

          Delayed nausea

          Aprepitant in combination with dexamethasone and 5HT3-antagonists is preferable if there is a high risk of delayed nausea and vomiting. This is offered especially to patients who have previously experienced delayed nausea.

          Conditional nausea

          In the event of conditional nausea, diazepam or other tranquilizers may be considered. Diversion or desensitization can be tried in more serious cases.

          Follow-up

          Ondansetron can have a constipating effect. Use of a laxative for several days should be considered.

          Nutrition during Cancer Treatment

          General

          Monitoring the patient's nutritional status is an important part of cancer treatment. The goal is to identify malnutrition as early as possible in order to initiate treatment as quickly as possible.

          Measures include diet according to symptoms and the nutritional condition. The patient should be offered nutrition-rich food, snacks, nutritional drinks, tube feeding and intravenous nutrition.

          Because cancer treatment breaks down both cancer cells and normal cells, the body requires an adequate supply of nourishment to increase growth of new cells. 

          In cancer patients, the sensation of hunger is not always present to the necessary degree. In these cases, it is important to take actions to improve the nutritional status of the patient. The nutritional condition is easiest followed by monitoring body weight over time.

          Indication

          • Cancer treatment (chemotherapy, radiation, surgery).

          Goal

          • Maintain nutritional status in order for the patient to have the best possible conditions for implementing treatment.

          Definitions

          Subjective Global Assessment (SGA)

          Subjective Global Assessment (SGA) is a scheme for classifying the patient's nutritional status.

          Other tables that are frequently used are Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment (MNA) and Nutrition Risk Score (NRS). In principle, these schemes are prepared in the same way as SGA, but they are not validated for patients with cancer.

          Weight loss is one of the most important signs of change in nutritional status. A weight loss of more than 15% over the past 6 months or more than 5% over the last month is a significant and serious weight loss. If the weight loss occurs in combination with low BMI (body mass index) (< 20 kg/m2 for adults) and/or a food intake of less than 60% of the calculated requirement over the past 10 days, the patient will be malnourished or be at nutritional risk.

          Calculation of nutrition and fluid requirements

          • Ambulatory patients:  30-35 kcal/kg/day
          • Bed-ridden patients:  25-30 kcal/kg/day
          • Elderly above 70 years:  Recommended amount is reduced by 10%
          • Fluid requirement:  30-35 ml/kg/day

          Nutritionally enriched diet / enrichment of food and beverages

          Nutritional beverages may be used as a meal in itself or between meals. Nutritional drinks can be a more valuable snack than "normal" food, because it is often easier for the patient to drink than to eat. It has been shown that if nutritional drinks are introduced as snacks, it does not affect the energy intake during the main meals.

          There are a number of ready-made nutritional drinks on the market. Some of the products are of nutritionally complete. They contain carbohydrates, protein and fat and are supplemented with all the necessary vitamins, minerals and trace minerals and possibly fiber. Some of these products can be used as the sole source of nutrition. The energy content varies from 85-200 kcal/100 ml and some products have a high protein content. Other nutritional drinks are supplement drinks adjusted to individual needs such as allergies, intolerance and special conditions associated with illnesses.

          The products are also adapted to age, and the dose is determined individually by a clinical dietician/doctor.

          Many patients prefer homemade nutritional drinks based on full fat milk, cream, ice cream, fruit and possibly flavor supplements. These are free of additives and have a fresher taste. The energy and protein content is close to the commercial products and at the same time they are more sensibly priced.

          Tube feeding

          Tube feeding is preferable to total parenteral nutrition (TPN) when the digestive system is working. Nutrition supply to the intestine is more physiological. It protects against bacterial growth, maintains the intestine's mucous membrane structure and function, and promotes motility. Tube feeding involves less risk of metabolic complications.

          Tube feeding is used in the event of

          • insufficient food intake (less than 60% of energy requirements) over the past 5-7 days despite oral intake
          • weight loss >2 % over the past week, >5 % over the past month or >10% over the past 6 months
          • danger of weight loss due to planned treatment
          • low albumin values (under 35 g/l, lower limit for normal area)
          • stenosis with feeding obstacles in pharynx/gullet

          Tube feeding must not be used for the following conditions.

          • Paralysis or ileus of the alimentary tract
          • Short bowel syndrome
          • Serious diarrhea
          • Serious acute pancreatitis
          • Obstruction of the intestine
          • Serious fluid problems

          Tube feeding solutions

          The tube feeding solution must be nutritionally complete because they shall be used as the sole source of nourishment. The most frequently used are standard (1 kcal/ml), fiber-containing (1 kcal/ml) or energy-rich (1.5 kcal/ml). There are also tube feeding solutions which are adapted to patients with digestion and absorption problems, patients with diabetes or lactose allergy, and intensive care patients.

          Tube feeding solutions, which are adapted to cancer patients are energy-rich (1.5 kcal/ml). They contain extra omega-3 fatty acids, rich in MCT acid and enriched with extra vitamins and minerals. Recommended dosage is 500 ml/day.

          Parenteral nutrition

          Parenteral nutrition should only be used if food by mouth or tube feeding cannot be maintained. Parenteral nutrition can also be used as a supplement to tube feeding or ordinary food. 

          Precautions must be taken for kidney failure, heart failure, lung failure, large fluid and electrolyte loss, diabetes mellitus and liver failure.

          Preparation

          The patient is classified as well-nourished, somewhat malnourished or seriously malnourished on the basis of information about weight development, food intake, symptoms and physical functioning. This classification has been shown to correlate well with more objective measurements of nutritional status and morbidity, mortality and quality of life.

          Actions include individual adjustment of diet according to symptoms and nutritional status.

          Tube feeding

          The end of the tube is often inserted into the stomach. In the event of poor gastric function, total gastrectomy or pancreatic resection, the feeding tube should be inserted in the duodenum or jejunum. The position of the feeding tube is vital for the choice of feeding-tube solution and mode of administration.

          The most common solution is to insert the tube nasogastrically, but it can also be done through the abdominal wall (PEG).

          Parenteral nutrition

          It is preferable to use intravenous or parenteral nutrition as a supplement to oral/tube feeding instead of only TPN (total parenteral nutrition).

          • Central veins must be used for TPN with high osmolality.
          • Peripheral veins can be used for short-term parenteral nutrition. In this case, a large vein on the forearm is used and a small needle. Nutrition is then given as more diluted solutions.

          Implementation

          All patients are weighed regularly (1–2 times each week). This is a prerequisite to being able to register changes in the nutritional status.

          Varied and healthy food contributes to the growth of new cells and enhances the immune system.

          • Fruit, berries and vegetables are rich in vitamins, minerals, antioxidants and fiber, which contribute to enhances the immune system and contributes to keeping the digestive system working.
          • Fish, shellfish, poultry, meat, eggs, cheese, milk, beans and nuts are rich in proteins, which are the building blocks of new cells.
          • Bread, rice, pasta, porridge and breakfast cereals supplement the diet with proteins, carbohydrates, fiber, vitamins and minerals.
          • Oil, margarine, butter, mayonnaise products, nuts, cream, heavy cream, desserts etc. are fat and energy rich products, which are important to maintain the energy intake at a satisfactory level.
          • Cancer patients also have a requirement for plenty of fluid, especially during treatment, to discharge waste.

          Often, the patients must have an individually adjusted diet. In the event of lack of appetite, it is generally more important that you eat (enough food) than what you eat (the right food). It is beneficial to have small portions and for the food to be as abundant in energy as possible. These patients will often have a need for 6–8 small meals everyday to obtain their energy requirements.

          Enrichment of food and drink is done in order to increase the energy content of the food product without increasing the volume. Full-fat products such as full-fat milk, cream, butter, heavy cream, mayonnaise, sugar, honey, eggs and cheese etc. are primarily used. Enrichment powders from pharmacies may also be used. Some powders are nutritionally complete, i.e. they contain everything the body requires in terms of energy and nutrients, while others only contain pure energy (carbohydrates, fat and/or protein). 

          Tube feeding

          Tube feeding is given continuously with a low drop rate or by interval/bolus administration (individually adapted meals with high drop rate).

          When the patient's energy and fluid requirements are fulfilled, it will be decided whether the patient will be given bolus or continuous supply at night, in order to increase mobilization during the day. However, this requires that the patient does not have diarrhea, nausea or other complaints associated with the supply of nutrition.

          For a running feeding tube:

          • Every 4-8 hours, it should be aspirated in order to monitor the gastric emptying. This applies especially to immobile and weak patients.
          • Weekly or more often, the nutrition program/fluid balance, evaluation, edema control, blood tests (albumin, K, Mg, P, blood glucose) should be monitored weekly or more often.
          • Every 4-6 weeks, the tube should be changed. Alternate the uses of nostrils avoid irritation in the nose through prolonged feeding.

          Experience shows that the use of infusion pumps causes fewer side effects and ensures correct volume and rate.

          Bolus supply

          Initiation of tube feeding with bolus supply is only recommended

          • if the patient been taking any food until the last 24 hours
          • if the patient is taking some food and requires tube feeding for additional nourishment

          It is recommended to use pumps for bolus supply for the first 1–2 days.

          Continuous supply

          If the patient cannot tolerate bolus supply (vomiting, abdominal discomfort, nausea, diarrhea), reverting to continuous supply should be considered.

          Tube feeding should always be administered continuously to very malnourished patients or if the tube end is located distally to the pylorus.

          Parenteral nutrition

          If the patient has a satisfactory nourishment status, begin with 100% of the requirement. If the patient is seriously malnourished, start with 80 % of the requirement and increase slowly to 100% over the course of three days.

          The patient must be monitored closely in relation to

          • electrolytes (potassium, phosphate and magnesium).
          • infusion rate.
          • twenty-four hour urine sample and fluid balance should be calculated daily.
          • glucose in the blood and urine, and electrolyte in the blood should be examined daily at the start.
          • liver tests, kidney function tests and triglycerides should be taken examined at least once every week.

          For TPN treatment longer than 1 month, vitamins and trace elements should be examined.

          Follow-up

          The patient's nutrition status should be monitored at follow-up visits after the end of treatment.

          Smoking cessation in connection with cancer treatment

          General

          In patients treated with surgery, radiation and/or chemotherapy, the treatment efficacy may be affected by smoking. Smoking has an impact on both metabolism and pharmacokinetics.

          Smoking may inhibit wound healing after surgery and increase the probability of surgical site infections. Because smokers generally have more mucus in the airways and are less able to remove it, they also may have a increased risk of serious lung complications during anesthesia. However, it is disputed whether or not it is beneficial to quit smoking directly prior to surgery and this should be considered in each case individually. (28,30-33). Smokers are more prone to stagnation of bronchial secretion than non-smokers and rapid postoperative extubation is important. 

          Patients who continue smoking during radiation therapy have a lower risk of complete respons, development of secondary cancer, increased toxicity and several other side effects compared to non-smokers and smokers that quit before treatment. Continued smoking during radiation therapy is also associated with oral mucositis, impaired ability to taste, dry mouth, reduced voice quality, weight loss, cachexia, fatigue, pneumonia, bone-and soft tissue necrosis.

          Tobacco may have an effect the metabolism and the mechanisms of chemotherapy and in this way may make the treatment less effective. Smokers undergoing chemotherapy may also experience a weakened immune system, increased rates of infection, exacerbation of common side effects, weight loss, cachexia, fatigue and cardiac or pulmonary toxicity. Some findings suggest that it may also apply to monoclonal antibodies.

          Cancer patients who quit smoking before chemo- and radiation therapy get a total symptom burden equal to that of non-smokers, but those who continue to smoke state a higher symptom burden. Targeted measures in smoking cessation may increase quality of life and lead to less treatment interruptions.

          A lot of patients wonder if there is any point to quit smoking after receiving a cancer diagnosis. tudies show that continued smoking is associated with increased treatment-related toxicity, increased risk of second primary cancers, reduced quality of life, reduced treatment effect and reduced survival in patients with cancer. This applies to both cancer diagnoses where smoking is a known causal factor, as with lung- and head and neck cancers and in cases where smoking has no known correlation with the diagnosis. Studies conducted on smoking and cancer diagnoses such as breast cancer, prostate cancer, colorectal cancer, esophageal cancer, cervical and ovarian cancer as well as leukemia and lymphoma cancers show that to continuation of smoking after a proven cancer diagnosis is associated with increased risk of mortality.

          Studies support that quitting smoking improves cancer, and emphasizing the potential importance of targeted smoking cessation in cancerpatients during and after treatment. The link between tobacco and impact on cancer and cancer treatment is a complex matter.

          Regarding the significance of the various components much is still unkown. When it comes to tobacco use in cancer treatment research is primarily done on the link between cigarette smoking and efficacy of cancer treatment. Nevertheless, it cannot be excluded that using other smokeless tobacco products such as snuff and chewing tobacco, may also impact the cancer treatment. According to international guidelines all tobacco use should be stopped during cancer treatment.


          Benefits of smoking cessation and risks of continued smoking in patients with cancer
          Quitting smoking results in the following benefits: Continued smoking results in a risk of :
          • improved treatment results.
          • less side effects
          • fewer infections
          • improved respiration and circulation
          • increased survival
          • reduced efficacy of treatment.
          • postoperative complications and longer recovery.
          • cardiovascular and respiratory complications.
          • recurrence of cancer, and secondary cancer.
          • shortened life expectancy.

           

          Indication

          Weaning of nicotine in connection to cancer treatment. 

          Goal

          Healthcare providers should convey evidence-based information to patients about how smoking affects cancer treatment, the risk of side effects and prognosis and also provide guidance and relevant treatment for smoking cessation.

          Preparation

          Patients require clear, formalized and fact-based guidance and continuous follow-up. Many patients want encouragement for smoking cessation early in the disease. Being hospitalized is a good opportunity because patients have access to support and help to reduce nicotine withdrawal symptoms and discomfort.

          A patient recently diagnosed with cancer is often motivated to quit smoking and also receptive to conversations about how to do this. Motivation or willingness to quit often changes during the treatment, and use of tobacco and motivation should therefore be discussed at every consultation.

          Clarifying the patient´s smoking habit is important. The time of day the patient lights their first cigarette says something about the degree of addiction. Making the patient aware of the situations in which he or she smokes most; at work, at home or in social settings, can help break unwanted patterns of behavior.

          Implementation

          The best and most direct approach to motivate the patient is telling that tobacco use will decrease the effectiveness of treatment and the most important thing the patient can do himself is to stop using tobacco.

          • Speak directly to the patient about how tobacco use may decrease the effectiveness of treatment.
          • Discuss smoking cessation with the patient at each visit.
          • Clarify any misunderstandings about the risks of tobacco use. Point out the importance of quitting.

          Sometimes there may be misunderstandings about what kind of health risk smoking during and after cancer treatment may entail.

          Advice to those who are not ready for smoking cessation
          The smokers statement The response of health care professionals
          Justifications
          The damage from smoking is already done.
          Some damage is done, but continued smoking will still damage your health and reduce the effects of treatment. Quitting smoking is more important now than ever.
          This response tells the patient that it is not too late to quit smoking, and the effect of treatment will be positive.

          I have reduced smoking.
          That is great, and now you need to focus on quitting completely. What do you think keeps you from quitting altogether?
          This response tells the patient the importance of quitting completely, as the benefits of quitting at baseline are documented.
          This is not a good time to quit smoking.
          The benefits of quitting are greatest now, before treatment begins. What is needed to make you feel ready to quit smoking?
           
          This response make the patient aware of the fact that quitting smoking optimizes the cancer treatment.

          Health professionals must assist the patient identifying realistic expectations and goals for smoking cessation. For some, it may feel easier to scale down the number of cigarettes than to quit completely. The patient should know that every puff affects their health, and that the total health benefits can only be achieved through smoking cessation. For patients unable to stop completely, a gradual reduction may be a step in the right direction.

          The probability of success for smoking cessation significantly increases for those who receive professional help in combination with nicotine replacement therapy (NRT) or non-nicotine based products. For the best possible effect of NRT the patient needs professional guidance to find the right product and dosage. For some patients combining two products or receiving a higher dosage than recommended will give the best effect. Sometimes the product must be replaced during the treatment.

          Treatment with nicotine replacement therapy

          Topical products are patches (Nicorette®, Nicotinell®), chewing gum (Nicorette®, Nicotinell®), lozenges (Nicorette®, Nicotinell®), inhalator (Nicorette®) or a combination of these. These products contain nicotine and therefore reduce the withdrawal symptoms experienced after smoking cessation.

          • Patch: Nicorette® 5 mg,10 mg and 15 mg/16 hours up to 6 months or Nicotinell® 7 mg,14 mg og 21 mg/24 hours up to 3 months.
          • Chewing gum: Nicorette®/Nicotinell® 2 mg and 4 mg, 8-12 pcs/day up to 12 months.
          • Lozenges: Nicorette® 2 mg and 4 mg, typically 8-12 pcs/day, maximum respectively 15 pcs/day up to 9 months or Nicotinell® 1 mg and 2 mg, typically 8-12 pcs/day, maximum is respectively
            25 and 15 pcs/day up to 12 months.
          • Inhalator: Nicorette® 10 mg/dosage container, 4-12 pcs/day up to 6 months.

          Combination therapy means combining patches with chewing gum, lozenges or an inhalator.

          • Nicorette® patch15 mg/16h and Nicorette chewing gum 2 mg. 5-6 chewing gums daily. Maximum 24 pcs/day
          • Nicorette® patch 15 mg/16h and Nicorette® inhalator 10 mg: 4-5 dosage-container daily. Maximum 8 pcs/day

          Nicotine replacement therapy increases the chance of smoking cessation by 50 to 70% after six months. Two products used in combination increase the chance of smoking cessation compared to the use of only one product.

          Side effects

          • Headache, dizziness, nausea, flatulence and hiccup.
          • Irritation in the mouth and esophagus using chewing gum/ lozenges/inhalator
          • Skin irritations while using patches.

          Precautions

          • Precaution in acute cardiovascular disease, peripheral arterial disease, cerebrovascular disease, hyperthyroidism, diabetes mellitus, kidney- and liver failure and peptic ulcers.
          • Should not be used during pregnancy, unless the potential benefit outweighs the potential risk.
          • The products should not be used during breastfeeding.

          Treatment with non-nicotine medications

          Bupropion (Zyban®) is a selective reuptake inhibitor of dopamine and norepinephrine. The mechanism behind why the ability to refrain from smoking increases by using bupropin is unknown. A should be set for smoking cessation for the second week of treatment.

          Bupropion increases the chance of smoking cessation after 6 months by nearly 70%.

          Side effects

          • Dry mouth, nausea, insomnia, hypersensitivity reactions and seizures (convulsions)

          Precautions

          • Contraindicated in people with disease that can cause convulsions,  people with substance abuse or other circumstances lowering the seizure threshold.
          • Depression, which in rare cases includes suicidal thoughts and – behavior including  suicide attempt.
          • Safety and efficacy have not been established for people under 18 years.
          • Should not be used during pregnancy.

          Varenicline (Champix®) is a partial agonist by a subtype of nicotinic receptors. It has both agonistic activity with lower intrinsic efficacy than nicotine and antagonistic activity in the presence of nicotine.

          A date for smoking cessation should be set. Treatment should start 1-2 weeks, or up to 35 days, before that date. The starting dose is 0,5 mg one time daily on days 1-3, then 0,5 mg two times daily on days 4-7, then 1 mg two times daily on day 8 and until the end of treatment. The treatment should last for 12 weeks.

          Side effects

          • Nausea, sleep disturbances, headache, constipation, flatulence and vomiting

          Precations

          • Links have been reported between the use of varenicline and an increased risk of cardiovascular events, suicidal thoughts, depression and aggressive and erratic behavior
          • Safety and efficacy have not been established for people under 18 years of age
          • Should not be used during pregnancy

          Follow-up

          If the patient experiences a relapse, it is important to inform them that this is completely normal, and encourage them to continue. If the most common measures do not work,
          consideration should be given both to increase the NRP and to provide closer follow-up by health care providers.

          Guidance in smoking cessation is described in the literature as brief and clear advice and then further follow-up with a telephone helpline offering treatment for addiction and behavior change/issues. It is not necessary for the patient to have decided to quit smoking in order to be referred to a quitline. If the patient agrees to receive a call from quitline, he or she will be followed up by a supervisor. Supervisors are bound by confidentiality, are up-to-date professionally and offer free follow-up counseling calls for up to a year.

          References

          1. Gritz E, Fingeret M, Vidrine D. Tobacco control in the oncology setting. American Society of Clinical Oncology, eds Cancer Prevention An ASCO Curriculum Alexandria, VA: American Society of Clinical Oncology. 2007.
          2. ASCO ASoCO. Tobacco Cessation Guide for Oncology providers,. 2012 (02.12.2014).
          3. Zevallos JP, Mallen MJ, Lam CY, Karam-Hage M, Blalock J, Wetter DW, et al. Complications of radiotherapy in laryngopharyngeal cancer: Effects of a prospective smoking cessation program. Cancer. 2009;115(19):4636-44.
          4. Obedian E, Fischer DB, Haffty BG. Second malignancies after treatment of early-stage breast cancer: Lumpectomy and radiation therapy versus mastectomy. Journal of Clinical Oncology. 2000;18(12):2406-12.
          5. Park SM, Lim MK, Jung KW, Shin SA, Yoo K-Y, Yun YH, et al. Prediagnosis smoking, obesity, insulin resistance, and second primary cancer risk in male cancer survivors: National Health Insurance Corporation Study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2007;25(30):4835.
          6. Van Den Belt-Dusebout AW, De Wit R, Gietema JA, Horenblas S, Louwman MWJ, Ribot JG, et al. Treatment-specific risks of second malignancies and cardiovascular disease in 5-year survivors of testicular cancer. Journal of Clinical Oncology. 2007;25(28):4370-8.
          7. Warren GW, Kasza KA, Reid ME, Cummings KM, Marshall JR. Smoking at diagnosis and survival in cancer patients. International Journal of Cancer. 2013;132(2):401-10.
          8. Hooning MJ, Botma A, Aleman BMP, Baaijens MHA, Bartelink H, Klijn JGM, et al. Long-term risk of cardiovascular disease in 10-year survivors of breast cancer. Journal of the National Cancer Institute. 2007;99(5):365-75.
          9. Li CI, Daling JR, Porter PL, Tang M-TC, Malone KE. Relationship between potentially modifiable lifestyle factors and risk of second primary contralateral breast cancer among women diagnosed with estrogen receptor–positive invasive breast cancer. Journal of Clinical Oncology. 2009;27(32):5312-8.
          10. Kenfield SA, Stampfer MJ, Chan JM, Giovannucci E. Smoking and prostate cancer survival and recurrence. JAMA - Journal of the American Medical Association. 2011;305(24):2548-55.
          11. Joshu CE, Mondul AM, Meinhold CL, Humphreys EB, Han M, Walsh PC, et al. Cigarette smoking and prostate cancer recurrence after prostatectomy. Journal of the National Cancer Institute. 2011;103(10):835-8.
          12. Phipps AI, Baron J, Newcomb PA. Prediagnostic smoking history, alcohol consumption, and colorectal cancer survival: The Seattle Colon Cancer Family Registry. Cancer. 2011;117(21):4948-57.
          13. Kountourakis P, Correa AM, Hofstetter WL, Lee JH, Bhutani MS, Rice DC, et al. Combined modality therapy of cT2N0M0 esophageal cancer. Cancer. 2011;117(5):925-30.
          14. Waggoner SE, Darcy KM, Fuhrman B, Parham G, Lucci J, Monk BJ, et al. Association between cigarette smoking and prognosis in locally advanced cervical carcinoma treated with chemoradiation: A Gynecologic Oncology Group study. Gynecol Oncol. 2006;103(3):853-8.
          15. Schlumbrecht MP, Sun CC, Wong KN, Broaddus RR, Gershenson DM, Bodurka DC. Clinicodemographic factors influencing outcomes in patients with low-grade serous ovarian carcinoma. 2011. p. 3741-9.
          16. Nagle CM, Bain CJ, Webb PM. Cigarette smoking and survival after ovarian cancer diagnosis. Cancer Epidemiol Biomarkers Prev. 2006;15(12):2557-60.
          17. Ehlers SL, Gastineau DA, Patten CA, Decker PA, Rausch SM, Cerhan JR, et al. The impact of smoking on outcomes among patients undergoing hematopoietic SCT for the treatment of acute leukemia. Bone Marrow Transplant. 2011;46(2):285-90.
          18. Talamini R, Polesel J, Spina M, Chimienti E, Serraino D, Zucchetto A, et al. The impact of tobacco smoking and alcohol drinking on survival of patients with non-Hodgkin lymphoma. International Journal of Cancer. 2008;122(7):1624-9.
          19. Toll B, Brandon T, Gritz E, Warren G, Herbst R. AACR Subcommittee on Tobacco and Cancer. Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement. Clin Cancer Res. 2013;19:1941-8.
          20. Arntzen A, Sandvold B. Hvordan veilede om røykeslutt? Sykepleien Forskning. 2010;5(3):182-90.
          21. Dresler CM. Is it more important to quit smoking than which chemotherapy is used? 2003. p. 119-24.
          22. Hsu CCT, Kwan GNC, Chawla A, Mitina N, Christie D. Smoking habits of radiotherapy patients: Did the diagnosis of cancer make an impact and is there an opportunity to intervene? J Med Imag Radiat Oncol. 2011;55(5):526-31.
          23. Richards J. Words as Therapy: Smoking Cessation. The journal of family practice. 1992;34(6):687-92.
          24. Cooley ME, Lundin R, Murray L. Smoking cessation interventions in cancer care: opportunities for oncology nurses and nurse scientists. Annual review of nursing research. 2009;27:243.
          25. Mazza R, Lina M, Boffi R, Invernizzi G, De Marco C, Pierotti M. Taking care of smoker cancer patients: a review and some recommendations. Annals of Oncology. 2010;21(7):1404-9.
          26. Waller LL, Weaver KE, Petty WJ, Miller AA. Effects of continued tobacco use during treatment of lung cancer. 2010. p. 1569-75.
          27. Peppone LJ, Mustian KM, Morrow GR, Dozier AM, Ossip DJ, Janelsins MC, et al. The Effect of Cigarette Smoking on Cancer Treatment-Related Side Effects. Oncologist. 2011;16(12):1784-92.
          28. Kuri M, Nakagawa M, Tanaka H, Hasuo S, Kishi Y. Determination of the duration of preoperative smoking cessation to improve wound healing after head and neck surgery. Anesthesiology. 2005;102(5):892.
          29. Krueger JK, Rohrich RJ, Mustoe TA. Clearing the smoke: The scientific rationale for tobacco abstention with plastic surgery. 2001. p. 1074-5.
          30. Nakagawa M, Tanaka H, Tsukuma H, Kishi Y. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest. 2001;120(3):705-10.
          31. Barrera R, Shi W, Amar D, Thaler HT, Gabovich N, Bains MS, et al. Smoking and timing of cessation: Impact on pulmonary complications after thoracotomy. Chest. 2005;127(6):1977-83.
          32. Mason DP, Subramanian S, Nowicki ER, Grab JD, Murthy SC, Rice TW, et al. Impact of Smoking Cessation Before Resection of Lung Cancer: A Society of Thoracic Surgeons General Thoracic Surgery Database Study. Annals of Thoracic Surgery. 2009;88(2):362-71.
          33. Gajdos C, Hawn MT, Campagna EJ, Henderson WG, Singh JA, Houston T. Adverse Effects of Smoking on Postoperative Outcomes in Cancer Patients. Ann Surg Oncol. 2012;19(5):1430-8.
          34. Alsadius D, Hedelin M, Johansson KA, Pettersson N, Wilderang U, Lundstedt D, et al. Tobacco smoking and long-lasting symptoms from the bowel and the anal-sphincter region after radiotherapy for prostate cancer. Radiother Oncol. 2011;101(3):495-501.
          35. Chen AM, Chen LM, Vaughan A, Sreeraman R, Farwell DG, Luu Q, et al. Tobacco smoking during radiation therapy for head-and-neck cancer is associated with unfavorable outcome. International Journal of Radiation Oncology Biology Physics. 2011;79(2):414-9.
          36. Eifel PJ, Jhingran A, Bodurka DC, Levenback C, Thames H. Correlation of smoking history and other patient characteristics with major complications of pelvic radiation therapy for cervical cancer. Journal of Clinical Oncology. 2002;20(17):3651-7.
          37. Bjarnason GA, MacKenzie RG, Nabid A, Hodson ID, El-Sayed S, Grimard L, et al. Comparison of Toxicity Associated With Early Morning Versus Late Afternoon Radiotherapy in Patients With Head-and-Neck Cancer: A Prospective Randomized Trial of the National Cancer Institute of Canada Clinical Trials Group (HN3). International Journal of Radiation Oncology Biology Physics. 2009;73(1):166-72.
          38. Browman GP, Wong G, Hodson I, Sathya J, Russell R, McAlpine L, et al. Influence of Cigarette Smoking on the Efficacy of Radiation Therapy in Head and Neck Cancer. The New England Journal of Medicine. 1993;328(3):159-63.
          39. Browman GP, Mohide EA, Willan A, Hodson I, Wong G, Grimard L, et al. Association between smoking during radiotherapy and prognosis in head and neck cancer: A follow-up study. Head Neck-J Sci Spec Head Neck. 2002;24(12):1031-7.
          40. Travis LB, Gospodarowicz M, Curtis RE, Clarke EA, Andersson M, Glimelius B, et al. Lung cancer following chemotherapy and radiotherapy for Hodgkin's disease. Journal of the National Cancer Institute. 2002;94(3):182-92.
          41. Ford MB, Sigurdson AJ, Petrulis ES, Ng CS, Kemp B, Cooksley C, et al. Effects of smoking and radiotherapy on lung carcinoma in breast carcinoma survivors. Cancer. 2003;98(7):1457-64.
          42. Dresler CM, Gritz ER. Smoking, smoking cessation and the oncologist. 2001. p. 315-23.
          43. Balduyck B, Nia PS, Cogen A, Dockx Y, Lauwers P, Hendriks J, et al. The effect of smoking cessation on quality of life after lung cancer surgery. Eur J Cardiothorac Surg. 2011;40(6):1432-8.
          44. Hamilton M, Wolf JL, Rusk J, Beard SE, Clark GM, Witt K, et al. Effects of smoking on the pharmacokinetics of erlotinib. Clinical Cancer Research. 2006;12(7 I):2166-71.
          45. Helsedirektoratet. Forberedelse til røykeslutt 2011. Available from: http://helsedirektoratet.no/publikasjoner/forberedelser-til-roykeslutt/Publikasjoner/forberedelse-til-roeykeslutt.pdf   
          46. Brunnhuber K, Cummings KM, Feit S, Sherman S, Woodcock J. Putting evidence into practice: Smoking cessation: BMJ Publishing Group; 2007.
          47. Helsedirektoratet. Røyketelefonen 2013 [updated 12.12.201102.12.2014]. Available from: http://www.helsedirektoratet.no/folkehelse/tobakk/snus-og-roykeslutt/royketelefonen/Sider/default.aspx.
          48. Legemiddelverk S. Legemidler A-Å 2013 [02.12.2014]. Available from: http://www.legemiddelverket.no/Legemiddelsoek/Sider/Legemidler_A-AA.aspx.
          49. Hughes JR, Stead LF, Lancaster T, Rev CDS. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews: Reviews 2007. 2014 (1).
          50. Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012;11(11).
          51. Cahill K, Stead LF, Lancaster T, Polonio IB. Nicotine receptor partial agonists for smoking cessation. Sao Paulo Med J. 2012;130(5):346-7

          Transfusions

          General

          Transfusions of blood components are often necessary for the patient to complete the planned cancer treatment.

          Blood transfusions are appropriate for low hemoglobin (Hb) and thrombocyte transfusions for low thrombocytes (trc) which also poses a risk for serious bleeding.

          Normal values

          • Hemoglobin 13.4–17 g/dl
          • Platelets 145–348 109/l

          Indications

          Blood transfusion

          Assessment for a blood transfusion based on:

          • Hb/hct
          • symptoms/sign/function level
          • underlying disease (heart/lung, serious infection)
          • expected development of anemia (marrow function, current bleeding)
          • acute blood loss > 15% of total blood volume
          • Hb < 8.0 g/dl and symptom causing chronic anemia
          • Hb < 8.0 g/dl and reduced bone marrow production without sign of regeneration
          • Hb < 8.0 g/dl in perioperative period
          • Hb < 7.0 g/dl in patients without symptoms of other disease
          • Hb < 10.0 and receiving radiation therapy

          Platelet transfusion

          The patient is assessed for thrombocyte transfusion based on:

          • clinical status (bleeding, bleeding tendency, or fever/infection)
          • ongoing bleeding and thrombocytopenia < 50x19/l
          • degree of thrombocytopenia and cause of thrombocytopenia (reduced production or increased consumption)

          Prophylactic platelet transfusion

          • For values < 10x109/l secondary to previous chemotherapy
          • Before invasive procedures
          • For spinal puncture and installation of central vein catheter, thrombocytes should be 30x109/l and 
          • Puncture biopsies (liver/kidney/tumor) > 40x109/l
          • For major surgeries, thrombocytes should be > 50x109/l. After surgery, thrombocytes should be monitored and transfusion repeated, if necessary.

          Remember clinical evaluations: possible bleeding, other risk factors for bleeding, diagnosis, treatment, prognosis.

          Goal

          • Complete the planned treatment
          • Ensure hemostasis 
          • Ensure adequate oxygen transport to peripheral tissue.
          • Maintain intravascular fluid volume for adequate circulations of vital organs

          Definitions

          Blood

          For a blood transfusion for anemia, SAGMAN erythrocytes are used. One unit is obtained from 450 ml blood. Most of the plasma is removed and replaced with 100 ml SAGMAN solution (Saltwater-Adenine-Glucose-Mannitol). Hematocrit is about 0.60%.

          Platelets

          One unit contains 240-300 x 109 platelets and is prepared from blood donors with type O and A. In acute situations, the receiver's blood group is of minor importance.
          Two kinds of platelet products are available:
          • Apheresis platelets produced from thrombophereses from one donor
          • Buffcoat platelets produced from buffy coat from 4 donors

          All cellular blood products should be leukocyte filtered. Leukocyte filtration is done to remove antigen-presenting and virus-bearing cells. 99.99% of leukocytes in the unit are removed.

          Radiation

          Blood and thrombocytes are irradiated to a minimum of 25 Gy in the blood bank to eliminate T-lymphocytes.

          This is done for:

          • Bone marrow transplant or stem cell transplant (1 month before or 3 months after HMAS until 1 year after allogeneic stem cell transplant)
          • For use of HLA-compatible platelet concentrations
          • For all transfusions from relatives
          • For use of fresh blood
          • For use of fludarabine

          Preparation

          Blood tests

          Before the first blood transfusion, the following blood tests are performed:
          • Virus antigens
            • HCV
            • HBV
            • HIV
          Every three days, and as needed, pre-transfusion tests are taken.

          Compatibility

          Erythrocyte concentration—Rh(D) negative products can usually be given to everyone while Rh(D) positive can only be given to Rh(D) positive receivers.

          Thrombocyte concentration—Rh(D) negative girls and women in fertile ages who obtain Rh(D) positive thrombocyte products should be given a prophylaxis for Rh immunization. Boys/men and women who are over the fertile age may obtain thrombocytes regardless of Rh(D) type.

          Implementation

          Blood components should never be given together with other medications.
          • Premedication if the patient has reacted to previous transfusions.
          • Secure venous access
          • The blood product is checked to ensure the correct unit is given to the correct patient.
          • Use blood set with filter
          • Give SAGMAN over 1 hour and thrombocytes 20-30 minutes per unit.
          • Rinse the set with NaCl 9 mg/ml at the end of the infusion
          • Store the blood product bag for one day before discarding

          Observations

          The patient should be observed during the transfusion with emphasis on reactions. Most serious transfusion reactions occur within the first 20 minutes.

          Symptoms of transfusion reaction:
          • chills
          • fever
          • feeling of heat in the face
          • breathing difficulty
          • itching
          • nervousness
          • fall in blood pressure
          • shock
          Suspect/manifest blood transfusion reaction:
          • Stop transfusion immediately
          • Start treatment if necessary (intravenous fluid, adrenalin, steroids, oxygen, respirator)
          • Check blood bag and compatibility form. The residue should be sent to the blood bank.

          Follow-up

          Hemoglobin and thrombocytes are checked.

          If poor effect of platelet transfusion, platelet value should be checked after approximately one hour. The value should have increased by approximately 30x109/l or more after a standard dose.

          If the increase is drastically less, the cause may be:
          • Abnormally high consumption. This is an indication for more frequent transfusions.
          • Antigens against HLA or platelet-specific antigens. The patient must be examined in cooperation with the blood bank to find compatible donors.

          Febrile Neutropenia

          General

          Febrile neutropenia occurs in compromised immune systems due to a low number of leukocytes, especially granulocytes. Patients with a declining number of granulocytes after chemotherapy, can during bacterial sepsis, quickly develop extensive neutropenia and become critically ill. Febrile neutropenia can be a life-threatening condition.

          A patient with neutropenia and simultaneous fever or clinical suspicion of systemic infection should be treated as quickly as possible with broad spectrum antibiotics including gram-negative and gram-positive coverage as soon as the required microbiological samples are taken.

          The clinical situation is most critical in patients who have not yet started antibiotic treatment. When broad-spectrum antibiotic treatment is started, monitoring the fever may be permitted.

          Fever is often the only symptom. Some have septicemia without fever. One should therefore also be aware of other symptoms such as lethargia, diarrhea, or visible sign of infection. The local clinical symptoms and signs (redness, pain, temperature increase, swelling (boil), and reduced organ function) are most often very much reduced or completely absent during neutropenia.

          Indications

          • A patient with neutropenia and simultaneously fever or clinical suspicion of systemic infection

          Goals

          • Avoid septicemia.
          • The patient is able follow the planned scheme of treatment.

          Definitions

          Fever is defined as:

          • a single (rectal) temperature ≥ 38.5 °C or
          • temperature ≥ 38 °C for more than 2 hours or
          • temperature ≥ 38 °C measured three times during 24 hours

          There is a known increase of infections when neutrophil < 1.0 x 109/l.  The infection risk increases with degree and duration of neutropenia. The neutropenia is considered severe when granulocytes are ≤ 0.5 x 109/l.

          Preparation

          The following diagnostic tests should be performed:

          • Adequate microbiologic tests: blood culture x 2-3, throat/nasopharynx, urine, catheter opening any surgical incisions. All blood cultures should be taken simultaneously to avoid losing valuable time.
          • Blood culture and other microbiological samples should be taken before antibiotic treatment is started
          • Blood tests with differential count of leukocytes, thrombocytes, Hb, CRP, SR, creatinine
          • X-ray of chest

          Information

          Before initiation of chemotherapy, the patient should be extensively informed, both verbally and in writing, of febrile neutropenia and  its consequences.

          A patient who can develop febrile neutropenia should obtain a written statement of the condition to present to other treatment providers.

          Use of an isolated or private room

          Patients with neutrophil granulocytes ≤ 0.3 x 109/l should have a private room if possible. Guidelines for protective isolation should be followed. Thorough washing of hands is especially important.

           

          Implementation

          • Treatment is started as soon as possible.  Treatment may be postponed a maximum of 30 minutes to complete microbiological testing.
          • Start septicemia treatment for fever if neutropenia is expected, regardless of granulocyte value.

          Antibiotic regimen

          • Benzylpenicillin sodium 5 mg IE x 4 tobramycin or gentamicin 5-10 mg/kg x1
          • Tazocin® 4 g x 3
          • Cefotaxime® 1 g x 4 if aminoglycoside should be avoided
          • Ceftazidim® 1 g x 4  with suspicion of pseudomonas infection
          • Meronem ® 0.5 g x 4 usually 2nd or 3rd choice

          When using aminoglycoside, the first dose should be high. Keep in mind the following:

          • age
          • sex
          • kidney function
          • fat index   

          Otherwise, the dose should be decided from concentration of aminoglycoside determined after the second day and thereafter monitored 2x per week. 

          Serum concentration of tobramycin and gentamycin

          For single dose in 24 hours

          • Trough concentration (0-test = 24 hour test) < 0.5 mg/l
          • Top concentration (30 minute after infusion is completed) > 12 mg/l

          For multiple doses in 24 hours

          • Trough concentration < 2 mg/l, top concentration (30 minutes after the infusion is completed) preferably > 8-10 mg/l 
          • Avoid aminoglycoside :
            • If kidney function is reduced. Avoid aminoglycoside if cisplatin is used. If cisplatin has been previously used, many patients will have subclinically reduced kidney function. If necessary, use aminoglycoside for a short period and monitor kidney function closely.
            • If carboplatin is used, determine glomerulus filtration rate (GFR) for each new treatment. Penicillin/aminoglycoside can be used if GFR is stable (has not declined more than 15% if initial value is in the normal range)
            • With sarcoma: Protocols with very high doses methotrexate and ifosfamid (> 5 g/m2) should be used in sarcoma treatment. It is not abnormal for these patients to have an increase in creatinine.
            • with massive ascites
            • with suspicion of or documented myeloma kidney (myelomatosis)
            • If aminoglycoside has been used in the past two weeks
          • Suspicion of staphylococcus aureus as a cause of infection (relatively rare)
            • Give penicillinase-stable penicillin, cloxacillin, or dicloxacillin, possibly clindamycin instead of ordinary penicillin. Yellow staphylococci are also killed by cefotaxime and by merop
          • Gram-positive cocci in multiple blood cultures and if the patient has clinical signs of infection
            • Use vancomycin 500 mg x 4 until resistance determination is available
          • Poor patient condition and suspicion of gram-negative septicaemia
            • Use “double gram-negative” with for example ceftazidim or tobramycin
            • Other preparations with good effects against most gram-negative bacteria are meropenem and ciprofloxacin
          • Suspicion of anaerobic infection
            • Use an anaerobic drug: Metronidazol 500 mg x 3, clindamycin 600 mg x 4, piperacillin/tazobactam 2g x 4 or meronem 500 mg x 4.  This especially applies if there is suspicion of anaerobic infection under the diaphragm such as gallbladder, intestines, perforation, abscess.
            • penicillin is often adequate for anaerobic infections above the diaphragm.

          With continuing clinical signs of infection, adjust the antibiotic treatment according to resistance determination in blood culture. Maintain gram-negative coverage.

          Systemic fungal treatment

          By persistent fever after multiple days with broad spectrum antibiotic treatment, one should consider empirical treatment of possible candida-sepsis, for example with fluconazole 600 mg the first 24 hours, and thereafter 400 mg x 1.

          If candida is documented without adequate response to fluconazole, a fungicide drug should be used, for example amphotericin B.

          If suspected infection with Aspergillus apply voriconazole, amphotericin B or caspofungin.

          Follow-up

          Observe for symptoms of a new infection.

          Bone Marrow Stimulation with G-CSF

          General

          Bone marrow stimulation with G-CSF (Neupogen®, Granocyte®) is only recommended for febrile neutropenia which does not respond to antibiotic treatment, severe neutropenia (granulocytes < 0.5 x 109 /L for more than 1 week), and in cases where it is necessary to administer curative treatment with sufficient dosage intensity.

          Indications 

          • To maintain dosage intensity for curative treatment; when a reduction in dosage will significantly reduce the chance of cure.
          • As prophylaxis for treatments associated with a high risk for febrile neutropenia (> 40 %)
          • Febrile neutropenia that does not respond quickly to antibiotic treatment
          • Long-lasting neutropenia

          Goal

          • Maintain treatment intensity

          Preparation

          The patient should be adequately informed about the treatment.

          Implementation

          • The dosage of Neupogen® is 5 µg/kg daily. The treatment is initiated, at the earliest, 48 hours after the treatment is completed. The treatment continues for 10 days.
          • The dosage of Neulasta® is 6 mg subcutaneously administered 24 hours after chemotherapy is completed. The neutrophil cells are counted on day 15.
          • The subsequent course is started on day 21, if the neutrophil count is 0.5 or higher, and the patient has not had febrile neutropenia.
          • It is important not to postpone the treatment if the neutrophil count is 0.5 or higher. The neutrophil count will compulsory decline after ending Neupogen® stimulation. Low values at the start of treatment should not be alarming if the values during hospitalization have been high enough to avoid febrile neutropenia.
          • Stimulation late in the cycle should only be performed for long-lasting, severe neutropenia. At least 48 hours should pass after completed stimulation treatment before the next chemotherapy course  is started. In these cases, it is always important to check that the doses are correct and to recalculate GFR etc. Continuation of chemotherapy will either require a drastic dosage reduction or secondary prophylaxis with G-CSF.

           

          Follow-up Care

          It is of utmost importance that the patient is informed of the risk of infections associated with a low neutrophil count.

          Patients at risk for developing  very low values, must be  informed to take their temperature if they feel unwell or  febrile. In case of  a temperature above 38 °C they should contact their doctor immediately.

          Intravenous Extravasation of Cytotoxic Drugs

          General

          Intravenous extravasation occurs when there is an accidental leak of intravenous cytotoxic fluid (chemotherapy drug) from the vein to surrounding tissue.  

          If chemotherapy is given in a peripheral vein, a large vein should be used, which is preferably in the underarm. Before the infusion begins, the vein should be checked for leaks by injecting NaCl 9 mg/ml or glucose 50 mg/ml. Backflow should also be checked. The patient must be informed that pain or burning in the area is not normal and they must inform the doctor.

          Cytotoxic chemotherapy drugs should always be given through a central vein catheter to reduce the risk of intravenous extravasation.

          Risk factors for intravenous extravasation:

          • Small veins (infants and children)
          • Brittle veins (elderly patients)
          • Reduced physical health (cancer patients)
          • Sclerosizing veins
          • Rolling veins
          • Poor circulation (if the needle is placed in an arm with edema)
          • Obstructed vena cava (raised venous pressure may cause leakage)
          • Conditions such as diabetes and radiation damage
          • Obesity

          Chemotherapeutic drugs are separated into three groups according to the degree of toxicity:

          • Non-cytotoxic/irritating
          • Tissue irritant
          • Cytotoxic

          Cytotoxic drugs can cause blisters or ulcerations leading to skin necrosis if extravasation occurs. If intravenous extravasation is left untreated, it can lead to permanent tissue damage, necrosis, scar formation around ligaments, nerves and joints, infections, abscesses, contractures, and in the worst case, amputation.

          Indication

          • Intravenous extravasation of cytotoxic drugs. 

          Goal

          • Limit damage of tissue from intravenous extravasation.

          Definitions

          Non-cytotoxic drugs or non-irritants

          Non-cytotoxic/non-irritant drugs normally do not cause skin necrosis.

          Irritants

          Drugs that are tissue irritants can cause pain in and around the injection site and along the vein. They can also cause inflammation. Some tissue irritating drugs cause ulceration if a large amount leak extravasally.

          Cytotoxic drugs

          Cytotoxic drugs are categorized into subgroups according to the mode of damage. This categorization is important for the choice of treatment.

          DNA-binding

          DNA binders absorb locally into the cells, bind to DNA, and cause cell death. After cell death, the drug molecule can be liberated from the dead cell and start killing healthy cells. This group is divided into these subgroups:  

          • Anthracycline
          • Alkylating drugs
          • Other

          For doxorubicin and mitomycin, progrediating tissue damage has been reported over weeks, and in some cases, months after intravenous extravasal injection.

          Non DNA-binding

          This group of medications can lead to cell death through other mechanisms than DNA binding drugs. This group is divided into:

          • Vinca alkaloids
          • Taxanes

           

          Chemotherapy cytotoxicity (1)
          Cytotoxic, necrosis

          Irritant, can cause flaking or inflammation

          Non-cytotoxic or non-irritant
          Amsacrine Cisplatin Aldesleukin
          Decarbazine Doxorubicin liposomal Alemtuzumab
          Dactinomycin Estramustine** Asparaginase
          Docetaxel**** Etoposide Bleomycin
          Doxorubicin* Floxuridine Bevacizumab
          Epirubicin* Florouracil Bortezomib
          Daunorubicin* Irinotecan Cetuximab
          Idarubicin* Carboplatin Cyclophosphamide**
          Irinotecan Carmustin** Cytarabine
          Kloremtin** Oxaliplatin Fludarabine
          Mitoguazon Pemetrexed Gemcitabine
          Mitomycin-C Ralitrexed Ibritumomab tiuxetan
          Mitoxanthrone Temoporfin Ifosfamide**
          Paclitaxel**** Teniposide Interferon
          Plicamycin Topotecan Cladribine
          Streptozocin Methylene blue***** Clofarabine
          Verteporphin   Melfalan**
          Vinblastine***   Methotrexate
          Vindesine***   Rituximab 
          Vincristine***   Tiotepa**
          Vinorelbine***   Trastuzumab

           * = Anthracycline

          ** = Alkylating agents

          *** = Vinca alkaloids

          **** = Taxanes

          *****= Methylene blue is not a chemotherapy drug, but is used for ifosfamide-induced encephalopathy, and is therefore included on the list.  

          All chemotherapy drugs can damage tissue in high concentrations.

          References

           

          1. Allwood M, Stanley A WP. The Cytotoxics Handbook. Ed. 4th ed. 2002. 2001
          2. Ekstravasation Guidelines Implementeringsværktøj [Online] 2007 [hentet 10. mars 2009]; Tilgjengelig fra URL: http://www.cancerworld.org/CancerWorld/getStaticModFile.aspx?id=2726

          Preparation

          Identification of an extravasal injection

          • A burning, stinging pain or other acute change of the puncture site.
          • Local redness or inflammation of the skin around the puncture site.
          • The infusion rate slows/stops.
          • Swelling of the puncture site.

          Extravasation has probably also occurred if blood cannot be aspirated, resistance is felt on the plunger when a syringe is used, and/or there is no current if the drug is infused. 

           

          Implementation

          Flow chart for treatment of intravenous extravasation of cytotoxic drugs:

          Emergency response:

          • Stop the infusion immediately.
          • Allow the needle to remain and aspirate with as much water as possible. Avoid applying direct pressure on the area of extravasation.  
          • The volume, type, and time of extravasation should be recorded.
          • A doctor/plastic surgeon should be called for to examine the patient.
          • The damaged area and skin manifestations should be marked/photographed.
          • The affected area should be kept elevated.
          • The remaining chemotherapy should not be discarded.
          • The patient should be informed about what is happening and what must be done. 
          • The needle is removed while aspirating.
          • Pain medication is administered if necessary.

          Based on which medication has leaked extravasally, the doctor or plastic surgeon will decide whether conservative treatment or primary surgery is necessary.

          Conservative treatment

          Conservative treatment consists of two different treatment strategies to limit the damage by extravasation: localize/neutralize and spread/dilute (2).

          Localize and neutralize:

          • Place an ice pack on the area for 15-20 minutes, at least 4 times daily for multiple days. A coldpack is used to limit spreading of the drug. Studies have indicated that there is reduced cellular uptake of drugs at lower temperatures (2).
          • The drug that has leaked extravasally is neutralized by a specific drug if the instructions are followed.
          • The affected area of the body should be kept elevated.

          Spread and dilute (applies to vincristine, vinorelbine, vindesine, and vinblastine):

          • Warm compresses are placed on the area for 15–20 minutes, at least 4 times daily, for multiple days.
          • To dilute the drug that has leaked extravasally, many subcutaneous injections are given with hyaluronidase diluted with sterile water.

          If the patient has lasting pain or blisters, surgical treatment should be considered by excising the area with direct sutures, skin transplant, or flap reconstruction.

          Another type of reconstruction may be necessary at a later time. 

          Treatment 

          Dexrazoxan (Savene®)

          Dexrazoxan is an EDTA analong used to treat extravasation of anthracycline (doxorubicin, daunorubicin, epirubicin, idarubicin). The mechanism of action is not fully understood, but it is believed that it may work through two mechanisms. By chelating iron, the formation of the iron-doxorubicin complex and  iron-mediated hydroxy radicals are hindered, which cause oxidative damage to cell membranes and proteins. Another possible mechanism is inhibition of topoisomerase II (3).

          Treatment lasts for 3 days. In all cases of extravasation of anthracycline, this treatment should be assessed by an oncologist and surgeon/plastic surgeon.

          • The first infusion should start as soon as possible and within 6 hours after extravasation. 
          • On the following two days, the infusions should occur at the same time as the previous infusion (+/- 3 hours).
          • If possible, the infusion should be placed in a vein where there is no extravasation.
          • An ice pack or cooling element used on the area must be removed at least 15 minutes before the infusion starts to ensure sufficient blood circulation.

          Cost

          A package costs about NOK 100,000.-. If the expiration date runs out, the drug is replaced by the pharmaceutical company free of cost.

          Dimethylsulfoxide (DMSO)

          DMSO (70–90% solution) quenches free radicals and prevents formation of sores. The solution can be used after extravasation of cytotoxic drugs (anthracycline, mitomycin C, doxorubicin, idarubicin, epirubicin andactinomycin D) together with cooling of the area when other treatment methods cannot be used (5, 6). DMSO cannot be used in combination with dexrazoxan (3, 4).

          • An area twice as big as the affixed area is treated with the solution every 8 hours for one week.(6)

          Hyaluronidase

          Hyaluronidase is an enzyme that breaks down hyaluronic acid found in connective tissue. This leads to permeability and increased diffusion of the drug that is leaking extravasally, and is used only to spread the drug out into the tissue (spread and dilute).  

          • Hyaluronidase is administered subcutaneously or intradermally in 5-10 locations on the border of the area where the drug has leaked extravasally (7).

          Surgical treatment

          "Wash-out"

          The washing out technique can be used with chemotherapy drugs when tissue damage is likely. When used with anthracycline, it is important that this is performed before the chemotherapy drug goes intracellularly.

          In most cases, this is a very successful method if it is performed within 6 hours after the extravasation.

          • The patient receives regional anesthesia.
          • Multiple small incisions must be made to ensure sifficient access to the damaged subcutaneous tissue.
          • With an infiltration needle, which is usually used for liposuction, isotonic NaCl is flushed through the tissue and drains through the incisions.
          • The infiltrated fluid is then carefully removed by suction through a small needle used for liposuction.
          • The procedure is repeated until 300-500 ml fluid is used.

          References

          1. Ekstravasation Guidelines Implementeringsværktøj [Online] 2007 [hentet 10. mars 2009]; Tilgjengelig fra URL: http://www.cancerworld.org/CancerWorld/getStaticModFile.aspx?id=2726
          2. Hasinoff BB. Dexrazoxane use in the prevention of anthracycline extravasation injury. Future Oncol 2008; 2006: 1–15.
          3. Statens legemiddelverk. Preparatomtale. 2008
          4. Langstein HN, Duman H, Seeling D, Butler CF, Evens GR. Retrospective study of the management of chemotherapeutic extravasation injury. Ann Plastic Surg 2002; 49: 369–74. 
          5. Bertelli G, Gozza A, Forno GB, Vidili MG, Silvestro S, Venturini M et al. Topical dimethylsulfoxide for the prevention of soft tissue injury after extravasation of vesicant cytotoxic drugs: A prospective clinical study. J Clin Oncol 1995; 13: 2851–5.
          6. Clinical Pharmacology© 2008 database. Hyaluronidase. 2008.

          Follow-Up

          For conservative treatment 

          The damaged tissue should be observed for multiple weeks (with mitomycin at least 13 weeks) since necrosis can occur after months.

          For emergency surgical treatment

          Patients treated by a plastic surgeon should receive follow-up care by the surgeon until the wound has healed.

           

          Intravenous extravasation of cytotoxic drugs.Intravenous extravasation of cytotoxic drugs.Extravasation of tissue toxic chemotherapy

          Follow-up care after cancer treatment in the colon and rectum

          Stage I (Dukes' A)

          Patients with stage I (Dukes' A) treated with comprehensive resection should generally not be followed up for development of distant metastases, but if it seems relevant in relation to the patient's age and general health condition, a new colon examination may be considered after 5-10 years. Cumulative risk of metachronous colorectal cancer is about 2% after 5 years and 3-4% after 10 years.

          Patients who have undergone local excision as curative or compromise operation should be followed-up at least every six months for five years to exclude local recurrence.

          Stage II and III (Dukes' B and C)

          All patients with stage II or III (based on the stage before any preoperative neoadjuvant therapy for rectal cancer) who are relevant for curative resection or oncological treatment if relapse/metastasis are detected, are evaluated based on age, general health- and medical condition.

          In patients over 75 years at time of diagnosis, controls are usually not relevant, but may be considered individually up to 80 years. The main criteria will be whether the patient is able to undergo extensive surgical and/or oncological treatment. In this age group benefits of a possible follow-up should be carefully considered. 85% of all recurrence is occurring the first three years and the follow-up should therefore be most rigorously during this period.

          After curative treatment

          The first control after surgery should be performed by a surgeon. Further checks are carried out by the patient's GP or local hospital. Patients operated with low anterior resection are checked by a surgeon. Anamnesis (altered bowel habits, rectal bleeding, discomfort, stomach /pelvic pain and cough) and a targeted physical examination will be emphasized. CT of the liver, lungs and examination of the primary tumor site every four months the first year is recommended.

          Follow-up for detecting recurrence

          Recommended guidelines for colon cancer where curative resection or oncological treatment of relapse / metastases may become relevant.
          Months postoperatively 1 6 12 18 24 30 36 48 60
          CEA x x x x x x x x x
          CT liver / abdomen x x
          UL liver with contrast x x x x x x
          Low-dose CT thorax x x x x x
          Colonoscopy or CT colography x
          Recommended guidelines for colorectal cancer where curative resection or oncological treatment of relapse /metastases may become relevant.
          Months postoperatively 1 6 12 18 24 30 36 48 60
          CEA x x x x x x x x x
          CT liver / abdomen x x
          UL liver with contrast x x x x x x
          Low-dose CT thorax x x x x x
          Colonoscopy or CT colography x
          Examination of rectum /perineum.
          Assessment of ailments related to function
          x x x x x x x x

          PROSEDYRER

          Long -term function after colorectal resection

          General

          After colon resection

          • For right-sided hemicolectomy the stools may be more frequent and the consistency softer, but this is rarely of clinical significance.
          • For subtotal and total colectomy as well as ileorectal anastomosis, the patient's stools get much looser than previously, the frequency is typically five times per day. Treatment with Imodium and possibly bulk-forming laxatives are relevant.

          After rectal resection

          • Protracted urinary retention due to damage of the autonomic innervation of the detrusor muscle of the bladder occurs in up to 5%. In rare occasions this becomes a permanent damage. Treatment with CIC (clean intermittent catheterization) is relevant. The ideal is to start early after surgery if the catheter removal on the fifth day led to urinary retention.
          • Impotence/reduced potency occurs in 25-50% of the patients, more frequent the longer distally the tumor was located. The reason is damage of the parasympathetic nervous system, most often by dissection anterolateral blistered /prostate, or by damage to the nerve roots S2-S5 on the pelvic wall. Remedies for erectile dysfunction may be attempted.
          • Retrograde or reduced ejaculation occurs in a few patients; this is caused by damage to the sympathetic nervous system at the pelvic entrance (The sympathetic hypogastric nerve).
          • Patients who manage to administer a well-functioning end colostomy have as good a quality of life as patients with low colorectal anastomosis.

          Feces function/low anterior rectal syndrome (LARS)

          After colorectal anastomosis the capacity and compliance of neo-rectum is reduced, the interaction between neo-rectum and the distal rectal mucosa / sphincter muscles are changed and sensibility in the distal rectal mucosa is often changed with reduced sensibility.

          This leads to the following changes:

          • Frequency - The patient has usually 3-5 bowel emptying per day.
          • Urgency - the urge to defecate is coming faster than before. This may be a social problem.
          • Incontinence - Light incontinence/soiling is relatively common.
          • Fragmentation - Patients rarely manage to complete emptying of the intestine when  visiting the toilet, but have to go back one or several times to achieve complete emptying.

          All these symptoms are most problematic during the first year and will gradually become better, but the end result is similar to what is mentioned above. All symptoms increases if the patient has had an anastomosis leakage. This will always heal with fibrosis, and the capacity/compliance is greatly reduced.

          Life with a stoma

          General

          A stoma changes lifestyle to different degrees as well as to body image, and practical and emotional questions will arise associated with this.

          A stoma is seldom a hindrance to resuming social life, but requires time to become accustomed to the change in bodily functions. Most can continue with recreational activities and work as before.

          The patient should obtain training in stoma maintenance and hygiene during the first days after the operation. The patient should quickly start maintenance of the stoma.

          Indication

          • Sigmoideostomy
          • Transversostomy
          • Ileostomy

          Goal

          • Live comfortably with a stoma

          Equipment

          • Stoma disc and pouch  
          • Unsterile compresser
          • Water
          • Stoma template
          • Pen
          • Scissors
          • Barrier cream
          • Waste pouch

          Remedies

          Barrier cream is a special cream intended for the skin around the stoma.The cream increases moisture and strengthens the skin. It contains little oil in order for the stoma to attach to the skin. The cream should be spread in a thin layer and excess cream should be wiped away after a few minutes for optimal attachment of the stoma disc.

          Barrier film is found as a spray or applicator and lies as a membrane on the skin as a protectant from bowel content.

          Stoma powder is used when the skin is sore and moist. The powder is sprinkled on moist areas and absorbs the moisture in order for the disc to attach itself. Powder on dry skin is blown away as this will reduce the adherence of the disc.

          Paste and gaskets allow for tighter bandaging where the skin around the stoma is uneven. Gasket paste contains alcohol and burns where the skin is sore. This can be avoided by sprinkling stoma powder on the skin first.

          Crystal violet 0.5% is a dye with antibacterial and antifungal properties. It will also dry out moist skin. The substance is spread with a cotton ball and allowed to air dry before a new skin disc is applied.

          Hydrocortisone cream 0.1% can also be applied to sore skin. The cream in an anti-inflammatory and should not be used more than 14 days in a row. The cream is massaged into the skin. Excess cream should be dried after a few minutes for optimal adherance of the stoma disc.

          Preparation

          When the patient is ready to carry out stoma changes, the situation should be as close to their home situation as possible. The patient can choose to sit or stand and it is recommended to carry out the change in front of a sink with running, temperate water. It is helpful to have extra room for equipment within reach.

          A bag for waste is attached to the trouser waistband to catch bowel content when the disc and pouch are removed.

          It may be appropriate to shave the area where the stoma disc will be attached for better adherence.

          Challenges regarding odor are greatest immediately following surgery. It is therefore recommended to change the bag in a well-ventilated room and/or to use a fan.

          Implementation

          Stoma care

          • To avoid spillage on clothing and to collect used equipment, the waste bag is attached to the waistband.
          • The stoma disc is loosened with a moist compress and carefully removed.
          • The skin and stoma are carefully washed with a lukewarm compress before it is dried/air dried/blown dry. It is the normal for the the stoma to bleed when touched.
          • Red, dry skin can be moistened with barrier cream in a thin layer. The cream should absorb into the skin for a few minutes before excess cream is dried away such that the disc will adhere to the skin.
          • The stoma template is cut out of cardboard or colorless, stiff plastic to the size of the stoma . A caliper can be used for measurement .
          • The stoma template is placed on the back of the new adherence disc and traced before adherence disc is cut and threaded over the stoma. Check that it sits properly on the skin.
          • A one component bandage consists of a complete bag with adhesive surface . The one component closed back is changed after every bag change which is usually 2-3 times a day. A one component reusable bag is changed daily or every other day.
          • A two component bandage consists of s skin disc and bag in two parts . The bag is threaded over the stoma and attached to the disc. The disc is usually changed 2-3 times per week. The closed, reusable bag is changed like a one component bandage and changed as needed.

          For a small intestine stoma, it is recommended to change the bag before breakfast because the bowel content comes almost immediately after the patient has eaten.

          Irrigation

          Irrigation is an alternative to a skin disc and back and is used in patients with a colostomy. The advantage of irrigating is that in between, there is little feces and bowel gases and the risk for odor and sound is less. Irrigation is time consuming (about one hour) which should be done every other day. Most patients therefore recommend using stoma bags.

          • A water holder with water regulation and an irrigation bag is required.
          • The colon is emptied by regular insertion of water enema.
          • The bowel is emptied every other day by using around 800-900 ml of body temperature spring water set via the stoma and in the bowel.
          • The stoma is bandaged in the end with a mini bag or Mini Cap with air filter with little/no space for bowel content.
          • At the Radium Hospital, stoma nurses are reponsible for training the patients in the technique.

          Follow-up

          Upon discharge from the hospital, the patient obtains stoma supplies for about 4 weeks. The patient should be checked regularly at a stoma clinic or by nurse or doctor in their home town.  Stoma patients need follow-up to assist with practical and emotional challenges.

          Stoma supplies can be obtained from a surgical store or pharmacy as a "blue prescription" § 3.1 in one year intervals. The equipment is specified on a stoma bandage card which is attached to the prescription. It is common to obtain equipment for a 3 month period. The patient should pay a copayment until they have a "free-card."

          Daily life

          A stoma itself is not a hindrance in the workplace or in daily life. For air travel, stoma equipment should be stored in hand luggage. Stoma equipment cannot be purchased on a "blue prescription" outside Norway. A shower can be taken with or without the bag. Bathing can done with the bag if the filter is covered. Tight clothing and waistbands which might squeeze the bag such that it does not fill properly should be avoided.

          Sexuality

          A stoma itself is not a hindrance for a normal sexual relations. Lack of energy and changes in body image after surgery may require time before sexual desire resumes. This will happen more quickly if partners are open about their relationship where both are able to express feelings and needs and have consideration for each other. If sexual relations become more difficult to master, it might be beneficial to seek professional help.

          Special conditions for females

          For stoma operated females who have removed the colon or rectum, the uterus can lean to the back in the empty space. The vagina can also be bent where a pocket can form in which discharge collects. The pocket is emptied by changing body position. It is helpful to rinse the vagina regularly with water containing a small amount of yogurt or a tablespoon of vinegar to one liter of water. This can be added to a an ear rinsing balloon which is obtained at a pharmacy.

          A bentover uterus may cause pain and during intercourse but can be avoided by choosing positions in which the female is not on her back. If the operation after cancer treatment has lead to nerve damage, reduced feeling and discomfort from vaginal dryness may occur. Lubrication jelly will help this.

          A stoma is not a hindrance for pregnancy and birth. Before the stoma is installed, the woman should discuss prevention and sterilization with her doctor and whether she plans on having children. The doctor can then take the necessary precautions.

          Special conditions for males

          The nerves in the groin area may be damaged during cancer treatment and surgery. This can lead to impotence and ineffective ejaculation. There are measures for impotence which may also be psychological and resume after time. It is important the patient is informed about this before the operation.

          Nutrition

          It is usually not necessary to change eating habits. It may be appropriate to resume the eating habits the patient had prior to surgery. Food that is tolerated is very individual and it is also necessary to try different foods. It is recommended to eat 4 medium-size meals a day. If one does not prefer to eat enough at each mealtime then snacks are recommended. Irregular mealtimes can cause irregular bowel motions and gas.  General advice is to chew food well, take time for meals, and drink at least two liters of water per day.  Food should have a low fat content and moderate amounts of fiber. Regular exercise with relaxation after mealtimes is recommended.

          Food which can cause constipation/ileus

          Nuts, fibrous foods such as asparagus, oranges, celery, seeded grapes, prunes, mushrooms, popcorn and corn shells, and fruit skin can cause constipation.

          Food which can cause gas

          Carbonated beverages, cabbage, onions, beans, sorbitol (artificial sweetener), chewing gum, and spicy foods can cause gas. Tea, caraway, fennel seed, and blanching of cabbage vegetables before boiling as well as physical exercise at a moderate tempo can be preventative. The pharmacy has over-the-counter products to prevent gas from accumulating.

          Foods which can cause thin stool

          Dried fruit, orange juice, pears, cherries, plumbs, hermetic fruit, alcohol, sorbitol, aspartame, sugar in large quantities, and fatty foods can cause diarrhea. Ripe bananas, blueberries, boiled potatoes, carrot puree, apple sauce, apple juice, pasta, rice, boiled milk, and peanut butter have the opposite effect. The pharmacy has over-the-counter products which improve the absorbance function of the bowel and can be taken in prevention and regularly.

          General advice for ileostomy operated patients

          Food can be salted extra due to loss of electrolytes through bowel movements. Food with a high fiber content should be chewed well to ease digestion and hinder enteralgia. It is recommended to take vitamin B12 due a lack of nutrient absorption in the lower part of the small intestine. Electrolyte mixtures are available at the pharmacy. Sport drinks can be taken used an alternative.

           

           

           

           

          Life with a stomaLife with a stomaLife with a stomaLife with a stoma

          Fatigue before, during, and after Cancer Treatment

          General

          There are many reasons why cancer patients feel fatigued. In many patients, the causes are synergistic. Cancer patients are often very sick during treatment periods and may experience extreme fatigue during intensive chemotherapy. It is also very important to be aware that fatigue is a symptom of many other medical conditions, both physical and psychological, which also affects cancer patients. Some known causes of fatigue associated with cancer and cancer treatment are: 

          • Cancer itself
          • An operation
          • Current or recently concluded chemotherapy
          • Current or recently finished radiation therapy
          • Severe anemia
          • Other symptoms such as pain and nausea 
          • Fever or infection
          • Too little fluid or food intake
          • Reduced lung function
          • Changes in sleep
          • Worries, anxiety, stress, or depression

          For some of these conditions, such as infections, there is medical treatment available. Fatigue that occurs after an operation or during chemotherapy and radiation therapy will, for most, gradually disappear when strength is regained. If a patient was feeling healthy after treatment and all of the sudden experiences fatigue, they should contact their doctor. If a patient feels fatigue and at the same time feels stressed, worried, or down, they may be reluctant to speak to their doctor or health personnel about it. It is still recommended to talk about these problems. Talking about it may be therapeutic, and provides room for discussing measures with a qualified person with experience with patients that have the same problems. For cured patients experiencing chronic fatigue, it may be difficult to pinpoint a specific cause. Many of these patients experience improvement by changing their lifestyle to a lower tempo than before the diagnosis.

          Definition

          Everyone knows what it feels like to be tired, fatigued, or lethargic when sick. This feeling is the most common side effect of cancer and cancer treatment. A symptom is a condition or state that something is not right in the body. Other frequent symptoms associated with cancer and cancer treatment are reduced appetite and nausea. Most patients who experience fatigue associated with cancer say that the feeling does not improve with rest, and many describe a lack of energy or exhaustion.  

          If fatigue arises during chemotherapy or radiation therapy, most patients experience that it will gradually go away when treatment is over and their strength is regained. This type of fatigue is considered acute. Improvement may take time depending on the intensity of treatment. Some patients experience that fatigue lasts for months, or even years. This is considered chronic fatigue. The ability to carry out daily activities, a lack of humor, health-related worries, a reduced capacity to carry out work functions, or less energy for family, can also accompany chronic fatigue. Most patients will find it difficult to be told by their doctor that they are considered healthy, while their friends and family expect them to be normal again, despite having a lack of energy and ability to perform activities they want to.  

          For many, feeling fatigued is often accompanied by having difficulty concentrating, poor memory, and an increased need for sleep. Most patients will need more sleep than before they became sick. For many, sleep is not restful, and it may take time to "get going" in the morning. Many also experience that they quickly become drained of strength if they exert themselves, and that it takes a long time before regaining strength after exertion. Exertion in this context can mean both physically and mentally such as working on a task that requires concentration.

          Preparation

          Fatigue can occur in all phases of cancer illness. Some patients feel it before the diagnosis, and almost all patients experience fatigue during radiation therapy or chemotherapy. A minority of patients experience long term fatigue after cancer treatment is over and the disease is cured. Patients who cannot be cured will almost always feel tired, worn-out, and exhausted. The degree of fatigue in these patients varies depending on the cancer type, spreading, and other symptoms of the disease.

          The patient should be given necessary information on both causes of fatigue and measures he/she can take.

          Implementation

          General measures that can reduce feeling tired and fatigued

          Following suggestions are meant as general advice that may not necessarily apply to everyone in all situations. This advice is based on results from studies, experiences from cancer patients, and recommendations from experts. Each patient should assess what works for them. It is recommended to express concerns and seek advice for what measures you can take and what you should avoid.

          General advice
          • Try to live as "normal" as possible.
          • Try to plan your day to include time to rest.
          • Take many small breaks during the day instead of a few long ones.
          • Rest after strenuous activity.
          • Plan your daily activities and do those that are most important for you.
          • Set realistic goals for yourself and try to be happy with those you accomplish.
          • Try to recognize activities that make you especially tired/fatigued and limit them, or spread them out over longer intervals. 
          • Try to accept that you do not have the energy to do the things you could previously.
          • Assess what is important for you to do yourself and what you can allow others to do.
          • Assume you will be tired after something strenuous even if you experience the activity as positive.

          Physical activity and exercise

          Exercise and physical activity that is appropriate for you will reduce the feeling of fatigue. Regular exercise is the most effective measure against chronic fatigue in cancer patients. Nevertheless, both too much and too little exercise can worsen fatigue, therefore, it is important to find a level (frequency and intensity) that suits you. You should never exercise so intensely that you must stop a session or exercise period because you are exhausted. Remember that daily form varies for everyone and adjust your exercise routine accordingly. Make long-term goals (months) and gradually increase activity, and carefully for a period. 

          • Activities such as walking, biking, swimming, dance, and aerobics are recommended.
          • Light exercise periods at regular intervals are better than intense, sporadic periods.
          • Always start with a slow tempo and increase gradually before finishing with a slow tempo again.
          • Always sit down and rest after exercise but try not to lay down and sleep.
          • Physical therapists and sport pedagogs can provide advice on exercises that are right for you. The principles are the same for all exercise, but it should be adjusted for your energy level.  

          Sleep

          Many cancer patients with chronic fatigue have sleep pattern disturbances. It is important to maintain a normal rhythm even if you feel like sleeping during the day.

          • Try to wake up at the same time every day and keep a regular bedtime.
          • Avoid too much activity right before bedtime.
          • Try not to sleep during the day because this will disturb your biological rhythm.
          • But, a short afternoon nap may be energizing!
          • Rest during the day by relaxing in a good chair, but try not to fall asleep.
          • Speak to your doctor about lasting sleep disturbances.

          Nutrition

          Having a reduced appetite or intake of food can also result in a lack of strength and energy. We recommend eating healthy food regularly, and to follow the national guidelines on nutrition. Special diets or supplements do not improve fatigue unless there is a deficiency.

          Work situation

          Some patients do not have the strength to continue working, or they must reduce their hours because of chronic fatigue. Consulting with a social worker may be beneficial for guidance regarding your work situation, your welfare rights, and financial situation. 

          Some adjustments that you and your employer can make:

          • Discuss the possibility for more simple or easier tasks, especially if you have a physically demanding profession.
          • Assess the possibility of reducing your hours.
          • Remember to take regular breaks also at work, if possible.
          • Assess the possibility of flexi-time to work during the hours you have energy, as well as the possibility of working from home.

          Care for children

          Caring for children or adolescents may be very difficult when you are fatigued or lack energy and strength. There are, however, some measures you can take:

          • Explain to your children that you are tired and are not able to do as much as you used to.
          • Discuss what the children can help you with and allow them to take part in household chores.
          • Try to establish permanent household chores for all family members.
          • Try to do activities that suit you that do not require too much energy, and can be performed without too much exertion. 
          • Ask and accept help from others for driving to and from activities, school, etc. if this relieves you.

          Drug therapy

          In Norway, there is currently no specific drug therapy for chronic fatigue associated with cancer. If the fatigue is due to specific conditions, this is of course treated with medication, if possible. Sometimes, such treatments improve the fatigue, but other times they do not. Examples of treatment that often reduce fatigue are treatment for infections and depression. 

          Treatment with medications that stimulate production of red blood cells is not recommended for cancer patients due the the danger of serious side effects.

          Follow-up

          Information about fatigue

          Healthcare workers in cancer care will often have knowledge about fatigue and cancer. Most general care physicians have general experience with fatigue but meet relatively few cancer patients. There is a lot of information available on the internet of varying quality. Below is a list of web adresses and some literature. Be aware that you may find opposing advice because knowledge on treatment especially, is limited.

          Some articles/books:

          • Armes J., m.fl. (2004). Fatigue in cancer. Oxford University Press.
          • Berger A.M., m.fl. (2009). NCCN Clinical Practice Guidelines in Oncology. Cancer-Related Fatigue. www.nccn.org
          • Patarca-Montero R. (2004). Handbook of cancer-related fatigue. Haworth Medical Press