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OVERVIEW

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Complete surgical resection of a primary non-metastatic colon cancer is the mainstay of treatment and holds the best chance for potential cure. The relative frequency of colorectal cancer by anatomic site of origin is shown in Fig. 108-1. Adequate resection involves removal of the involved segment of large bowel, mesentery, and associated vascular supply to completely excise the lymphatics, which harbor metastatic disease. At least 12 lymph nodes should be removed and pathologically evaluated to determine stage.1 Laparoscopic colectomy after diagnosis of colon cancer is now an accepted approach that is not inferior to conventional open surgical resection. The Clinical Outcomes of Surgical Therapy (COST) trial randomized 827 patients with colon cancer to open or laparoscopic operations, noting no significant differences in overall survival.2 The data show that patients in the laparoscopic group recovered faster, used less pain medications, and had no more short-term morbidity or mortality compared with the open group.

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Figure 108-1

Anatomy of the colon and frequency of tumor.

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Robotic surgery has come to the forefront as a modality that improves upon the mechanical disadvantages of laparoscopic surgical techniques. In recent work, a meta-analysis reviewing 39 case series, 29 comparative studies, and one randomized trial indicates that robot-assisted colorectal surgery is safe and feasible when compared with laparoscopic and open surgery. The oncologic outcomes have been similar in the robot-assisted surgery groups. Less blood loss, shorter hospital stay, fewer conversions, and lower complication rates were noted when compared with laparoscopic or open resections.3

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The American Society of Colon and Rectal Surgeons (ASCRS) has put forth a set of practice parameters for the management of colon cancer, based on grades of evidence,4 in support of specific preoperative assessment and treatment strategies. Guidelines put forth by both the National Comprehensive Cancer Network (NCCN) and the American Society for Clinical Oncology (ASCO) are also important in determining optimal delivery of best care to patients.5 Here, we will discuss the existing strong treatment recommendations in settings, where benefits clearly outweigh risk (grade 1A to 1C). It is beyond the scope of this chapter to explore the details for each topic, but the general recommendations are highlighted.

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To begin, a thorough history and physical examination and routine laboratory analysis, including CEA, should be part of the initial work-up of patients with colon cancer. Additionally, every patient should undergo a full colonic evaluation, with histologic analysis of the colon lesion, prior to initiation of treatment. If colonoscopy is incomplete, then short interval postoperative (3-month) colonoscopy should be performed. Radiologic staging should also be part of routine preoperative work-up. Staging of the disease should be done in accordance with the American Joint Committee on Cancer (AJCC)/Tumor Node Metastasis (TNM) system.

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From an operative standpoint, a thorough exploration should be performed and documented; to ...

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