28 Surgical Management of Colon Cancer

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28

Surgical Management of Colon Cancer

Anthony J. Senagore and Robert Fry

395 All colorectal adenocarcinomas develop from a single trans-

formed cell which through numerous cell divisions unim- peded by cell death forms a macroscopic lesion involving the lumen of the bowel. The staging of colorectal cancer assesses the depth of penetration of the bowel wall, the involvement of regional lymph nodes, the involvement of adjacent organs, and the presence or absence of distant metastases. An increasingly wide variety of putative molecular markers for aggres- siveness and metastatic potential have been analyzed;

however, the most accurate prognostic indicator remains the true stage of the cancer. This fact is the basis for recognizing adequate locoregional oncologic principles when performing curative resections of colon cancer. The purpose of this chapter is to primarily address issues directly related to the safe and oncologically sound methods of performing a curative resection of a colonic carcinoma. Important and related issues, such as clinicopathologic staging systems, the role of adjuvant or neoadjuvant treatments, and molecular markers are addressed in detail in other sections of this text.

Preoperative Preparation

Planning an operation for a patient with colon cancer requires the surgeon to have as much understanding as possible of the tumor’s location in the bowel, the stage of the cancer, and the patient’s physiologic status.

A variety of scoring systems are available for grading operative risk of surgical patients. The most widely applied scoring system is the American Society of Anesthesia score (1–4);

however, this tool only provides information regarding the risk of an anesthesia complication given a certain physiologic status.^1,2A more recent tool is the POSSUM and the modified p-POSSUM which include the additional risks related to underlying nutritional status and the performance of a colectomy.^3–5These tools, although of limited specificity for the individual patient, do provide an estimation of the relative risks for both the patient and the entire surgical team.

Localization of the tumor and the histopathology are important data elements that allow preoperative selection of an operative plan and selection of the optimal resection margins. The presence of a lesion at watershed areas of vascular supply such as the hepatic and splenic flexures may require more extensive resection of colonic length for a safe and complete oncologic procedure. An extended right or left colectomy may be indicated to remove all contributing vascular supplies. In addition, information consistent with the hereditary nonpolyposis colon cancer (HNPCC) (right-sided lesion, Crohn’s-like inflammatory response, young patient, and positive family history) would support the resection of the abdominal colon rather than a simple segmental resection. This diagnosis may also be supported by special stains of the biopsy specimen which demonstrate microsatellite instability, the hallmark of the disease which develops from mutations in the DNA mismatch repair system.

Colonoscopy is widely used today and represents the optimal means of diagnosing the lesion, identifying location, providing histopathologic material, and tattooing for intraoperative localization when required. Contrast enema is another means of localizing the lesion anatomically which should be considered to localize a lesion when colonoscopy fails to clearly define the portion of bowel involved. Computed tomography (CT) allows the localization of larger lesions, identification of local organ invasion, and provides important staging information regarding the presence of extracolonic disease, particularly liver involvement. Although intraoperative ultrasound may provide this information, most surgeons will obtain a CT as a screening tool (see Practice Parameters).

Although positron emission tomography has recently been approved for colon cancer staging, in isolation its role in assessing the majority of primary, curable lesions remains speculative. It may be very useful for recurrent cancer, where it is essential to determine the presence of disease outside the scope of resection and may provide evidence of widely metastatic disease when planning a radical resection. Thus, an unnecessary noncurative operation with high morbidity may be avoided.

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Bowel preparation has historically been considered an essential component of the preoperative preparation of the patient with colon cancer. The performance of mechanical cleansing combined with oral antibiotics reduces the concen- tration of aerobic and anaerobic bacteria within the colon and has been shown to decrease the incidence of wound infection from 35% to 9%.^6–8However, more recent prospective, randomized studies have questioned the additional benefit of luminal preparation, compared with the use of appropriate intravenous antibiotics administered in a timely manner. A recent metaanalysis by Bucher et al.⁹reviewed 565 patients with a mechanical bowel preparation versus 579 without a preparation. Interestingly, all but one study demonstrated a higher anastomotic leak rate in the mechanical preparation group with an odds ratio of 1.8.^10,11Other surgical site infec- tious complications were also more frequent in the mechanical preparation group. However, most of these studies included high-volume polyethylene glycol in the preparation group. Similar conditions may or may not apply to bowel preparation with the lower volume sodium phosphate preparation. Selective use of mechanical bowel preparation in combination with systemic antibiotics may be justified.

A mechanical bowel preparation is still advantageous for laparoscopic colectomy because the reduction in stool volume within the colon makes manipulation of the bowel easier with the small instruments and reduces the size of the extrac- tion site.

Surgical Technique

There are many approaches to the technical performance of each segmental colonic resection. This description will provide general technical methods and document standard anatomic landmarks that should be common to all patients.

Right Colectomy

The patient is placed supine on the operating table. The modified lithotomy position may be useful in cases in which intraoperative endoscopy is necessary. A vertical midline incision is made sufficiently long to allow complete visualization of the operative field. A self-retaining retractor should be placed so as to allow the entire surgical team free hands to conduct the procedure. Thorough examination of the abdominal and pelvic contents should be performed. Particular attention should be given to potential metastatic sites, especially the liver. The increasing use of intraoperative ultrasound has demonstrated the superiority of liver assessment of this modality compared with clinical examination or CT. In the female patient, the ovaries should be examined not only for the risk of metastatic deposits, but also for primary neo- plasms. The resectability of the tumor should be assessed with minimal manipulation of the lesion. It is important to determine the presence of disease adherent to adjacent viscera

which should be included with an en bloc resection. It is rare for cancer of the right colon to be unresectable; however, extensive involvement of the vena cava, superior mesenteric artery, or the pancreas may necessitate a palliative resection or bypass procedure.

The key to an oncologically safe and effective resection of a colon cancer requires clear lateral margins, resection of the locoregional lymph node bearing mesentery for both cure and staging, and fashioning of an accurate and well-vascularized anastomosis. Therefore, a right colectomy is required for a tumor at any location in the ascending colon. The author prefers the medial to lateral “no touch” technique. However, the section senior editor prefers the lateral to medial technique. Thus, as can be seen, both approaches are acceptable alternatives.

The Medial Approach

The resection begins with exposure of the right colon mesentery by reflecting the small bowel to the left side of the abdomen. The right colic artery (present in 50% of cases) and the ileocolic vessels can be elevated from the retroperitoneum.

A vertical incision is made at the root of the right colon mesentery just caudal to the third portion of the duodenum to the right of the superior mesenteric artery (see Figure 28-1). The vessel(s) is elevated off the retroperitoneum and a proximal ligation is performed at the origin off the superior mesenteric

FIGURE28-1. The drawing demonstrates the incision made at the root of the right colon mesentery just caudal to the third portion of the duodenum to the right of the superior mesenteric artery.

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artery (see Figure 28-2). The right colon mesentery is then dissected off the retroperitoneum. This will allow identification of the hepatic branch of the middle colic artery (MCA) as the transverse colon is approached rostrally. Dissection caudally toward the terminal ileum permits ligation of the ileal vascular branches. The right colon can then be released from its peritoneal attachments laterally along the right gutter and trans- versely over the right iliac artery and brought to the midline.

The hepatic flexure suspensory ligaments should be carefully divided to avoid injury to the common bile duct and should be secured with energy or ligatures because of large veins in the ligament. The terminal ileum should be divided 5–15 cm proximal to the ileocecal valve to ensure good vascular supply (see Figure 28-3 for extent of resection). The transverse colon is divided just to the right of the main trunk of the MCA. The right branch of the MCA may be taken, if required. The attached omentum over the right side of the transverse colon should be resected with the specimen. The ileocolic anastomosis can be fashioned according to the desire of the operating surgeon. The author prefers to divide the ileum and colon with linear staplers and perform a functional end-to-end anastomosis by anastomosing the antimesenteric surfaces of the bowel segments with a linear cutting stapler and closing the remaining colotomy with a transverse application of the linear stapler. Closure of the mesenteric defect is optional but may be appropriate to prevent trusion of the small intestine around the terminal ileal vascular pedicle.

Lateral Approach

Dissection of the right colon may begin laterally along the peritoneal reflection fold which attaches colon to retroperitoneum. The avascular plane between mesentery and retroperitoneum should lead the dissection over the kidney and duodenum from the lateral aspect to make the right colon a midline structure. Vascular ligation can be performed as the final step in the same sites as for the medial approach.

Extended Right Colectomy

An extended right colectomy should be performed for any lesion involving the transverse colon including the hepatic and splenic flexure. This procedure requires proximal ligation of the middle colic vessels which are preserved in a standard right hemicolectomy (see Figure 28-3). Once again this accomplishes complete resection, lymph node clearance, and most importantly two well-vascularized bowel segments for anastomosis.

The operation proceeds in similar manner as the right colectomy described above. However, rather than proceeding through the transverse colon mesentery to ligate and divide the right branch of the MCA, dissection continues in the retroperitoneal plane to identify the main middle colic arterial trunk anterior to the pancreas. This vessel is ligated and FIGURE28-2. The vessel(s) is elevated off the retroperitoneum and a

proximal ligation is performed at the origin off the superior mesenteric artery. The surgeon’s finger is used to demonstrate the vascular origin for accurate placement of the ligation.

FIGURE 28-3. The drawing demonstrates the appropriate levels for vascular ligation and colonic transition for a right hemicolectomy.

Notably, the transverse colon is divided just to the right of the main trunk of the MCA, although the right branch of the MCA may be taken, if required. The middle colic vessels are demonstrated and may be ligated during the performance of an extended right hemicolectomy. This leaves the descending colon in place supported by the left colic artery.

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divided. The right colon is then mobilized medially as before and then the lesser sac is entered through the gastrocolic ligament outside the gastroepiploic artery so that the omentum can be resected with the transverse colon. The splenic flexure is released from the tail of the pancreas, tip of the spleen, and anterior surface of the left kidney. The left colon and mesentery are divided just proximal to the left colic artery which is preserved for right-sided lesions. The left ascending colic may be sacrificed for left transverse colon lesions preserving the left descending and sigmoid vessels, where a more distal colonic (ileosigmoid) anastomosis is desired. The ileocolic anastomosis is then constructed based on surgeon preference with functional end-to-end/side-to-side technique or end-to- end technique.

Left Colectomy The Medial Approach

The small bowel mesentery is mobilized to the right upper quadrant to expose the origin of the inferior mesenteric artery (IMA) (Figure 28-4) located just caudal to the third portion of the duodenum (see Figure 28-4). An incision running along the base of the left colic and sigmoid mesentery from the sacral promontory to the ligament of Treitz, exposes the aorta, bifurcation of the common iliac arteries, and IMA vein. The IMA is ligated and divided proximal to the origin of the left colic artery and the inferior mesenteric vein (IMV) is ligated at the base of the pancreas. The avascular plane filled with areolar tissue is developed beneath mesentery and left colon along the entire left gutter. The left ureter is easily identified at this stage and should be freed from overlying mesentery to avoid injury before vascular ligation. The mesentery is elevated off the retroperitoneum and the sigmoid colon mobilized from the pelvic ileum. The left colon is finally mobilized medially from its lateral abdominal wall attachments and the splenic flexure is released. The attachments to the left kidney, tail of the pancreas, and tip of the spleen can be released bloodlessly. Once again, the omentum should be taken with the left transverse colon. The left MCA in the base of the transverse colon mesentery is divided to preserve blood flow to the right transverse colon from the right MCA.

Occasionally, it may be necessary to divide the right MCA to allow the right transverse colon to reach the sigmoid for an anastomosis. However, an extended right colectomy and ileosigmoid or ileorectal anastomosis may be preferable if there is any concern related to the blood supply of the distal right colon as the proximal component of the anastomosis.

Another alternative is to perform a retroileal right colon to rectum anastomosis if maintenance of the right colon is desired. This is performed by swinging the fully mobilized colon in a counterclockwise direction down into the pelvis to place the cut edge of the right colon mesentery across the pelvic brim (Figure 28-5). Once again the anastomosis is left to the discretion of the surgeon.

The Lateral Approach

An incision is made first at the attachments of the sigmoid colon at the pelvic brim and then along the left gutter medial to the white line of Toldt. An areolar tissue plane is found between the mesentery of the left colon and retroperitoneal structures which can be bluntly dissected as far as the midline. The splenic flexure is mobilized with this plane as the guide. Finally, the medial incision is made along the base of the left colon mesentery to expose the IMA and IMV as described above. The procedure proceeds as for the medial approach.

Sigmoid Colectomy

High ligation of the IMA (Figure 28-4) is necessary when performing a sigmoid colectomy to remove all of the lymphatic drainage, and more importantly to ensure construction of a tension-free anastomosis. The ascending branch of the left colic artery should be preserved to allow retrograde blood flow via the marginal artery from the middle colic arterial supply.

The splenic flexure should be released to avoid anastomotic FIGURE28-4. The small bowel mesentery is mobilized to the right upper quadrant to expose the origin of the IMA located just caudal to the third portion of the duodenum (see Figure 28-4). An incision running along the base of the left colic and sigmoid mesentery from the sacral promontory to the ligament of Treitz, exposes the aorta, bifurcation of the common ilial arteries, and IMA vein. The IMA is ligated and divided proximal to the take-off of the left colic artery.

The left branch of the middle colic vessels will require ligation and division for a formal left colectomy.

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tension. The sigmoid colon is mobilized to the level of the middle colic vessels medial to lateral or lateral to medial and the proximal rectum is mobilized from the sacral promontory.

The patient is always in modified lithotomy position to allow transanal access for the anastomosis. An end-to-end circular stapled anastomosis can be performed between proximal left colon and rectum, after dividing the rectosigmoid junction with a transverse linear stapler. A leak test with air insufflation of a submerged anastomotic segment should be performed in all cases using either an endoscope or bulb syringe.

Total Abdominal Colectomy with Ileorectal Anastomosis

This procedure may be required for circumstances in which the patient has been diagnosed with HNPCC, attenuated famil- ial adenomatous polyposis, metachronous cancers in separate colon segments, and frequently in acute malignant distal colon obstructions with unknown status of the proximal bowel. The access to vascular supply and mesenteric dissection has been

described above. The terminal ileum should be sufficiently mobilized to allow easy reach to the rectum. A circular stapled end-to-end anastomosis or functional end-to-side/side-to-side anastomosis are both appropriate. Proper sizing of the circular stapler is needed to avoid ischemia and stricture.

Special Circumstances

Acute Obstruction

Acute colonic obstruction produces dilated bowel with a large amount of fecal loading proximal to the blockage. The associated bacterial overgrowth coupled with possible impairment of blood flow in the proximal bowel, have been the primary factors that have classically dictated resection and proximal diver- sion. Lee et al.¹² compared left- and right-sided resections managed by primary anastomosis and found similar leak rates (left 6.9% versus right 5.2%) and mortality rates (left 8.9%

versus right 7.3%) when compared with historical nonob- structed controls (< 2% and <1%, respectively).^12–16On-table colonic lavage has been advocated as an alternative means of dealing with the obstructed colon. Several cohort studies have demonstrated the safety and efficacy of this approach for avoiding a colostomy without increasing leak rates (< 5%) or sepsis.^14–16 Another approach at attempting to protect at-risk anastomoses has been omental wrapping. A large prospective randomized trial by Merad et al.¹⁷did not demonstrate any sig- nificant difference in anastomotic leak rates or the sequelae of those leaks. A complete resection of the tumor and obstructed proximal bowel with primary ileocolic anastomosis has been shown to be safe and carry low leak rates.¹⁸

Prophylactic Oophorectomy

The debate continues regarding the relative risks and benefits of a prophylactic bilateral oophorectomy in women with colon cancer. The potential benefits are removal of an ovary seeded by colon cancer cells which will manifest as a delayed metastatic site and reduction in the risk of primary ovarian cancer in this age group. The data are limited for both issues.

A randomized trial of prophylactic oophorectomy has shown no benefit to survival.¹⁹The risk of micrometastatic implants in the ovary increases with Dukes’ stage and approaches 10%.^20,21A comparison of cohorts of women with and without prophylactic oophorectomy could not demonstrate a survival advantage but a 3.2% versus 0% risk of primary ovarian cancer in survivors with ovaries not resected.²² In general, prophylactic oophorectomy is not performed.

Colon Cancer and Abdominal Aortic Aneurysm

The simultaneous presence of a colorectal cancer and abdominal aortic aneurysm which requires surgical management causes a clinical dilemma in many situations. A survey of FIGURE28-5. An alternative method of reconstruction that preserves

the right colon is a retroileal right colon to rectum anastomosis. This is performed by swinging the fully mobilized colon in a counterclockwise direction down into the pelvis to place the cut edge of the right colon mesentery across the pelvic brim.

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general surgery program directors revealed that vascular surgeons preferred to repair the aneurysm first, whereas the non- vascular surgeons preferred colectomy.²³The primary risk is that performing either operation first may cause complications that significantly delay the second procedure. The risk of performing a colectomy synchronously with placement of graft material is a graft infection; however, this risk does not seem excessive based on the small data sets available.^23–27In all likelihood, the best guidance suggests that any aneurysm

>6 cm should be repaired first or synchronously in the face of an associated colon cancer to avoid the risk of rupture.²⁵ Endoluminal grafting of an appropriate aneurysm may elimi- nate the majority of these quandaries in the future.²⁵

Synchronous Management of Colon Cancer and Liver Metastases

The potential benefit of simultaneous colectomy and hepatectomy is the avoidance of two laparotomies and possible reduction in operative risk. Conversely, delayed management of colonic hepatic metastases offers the ability to accurately stage patients and avoid the risk of hepatectomy in a group of patients who will prove to have more widely metastatic disease in several months. Selection of patients who have limited hepatic involvement and who are positron emission tomography negative for distant disease has resulted in increased resectability and 5-year survival after hepatectomy.²⁸ The risks of simultaneous colectomy and hepatectomy do not seem to be excessive in select patients operated by expert groups.^29–31 However, the risks may be less with smaller nonanatomic liver resections coupled with right colectomy.

Radiofrequency ablation will be discussed in Chapter 34.^32,33

Sentinel Node Assessment

Sentinel node assessment was first described as a means of improving staging and treatment for melanoma patients and is currently considered standard of care for breast cancer patients.^34,35Saha described the application of sentinel node identification for colorectal cancer patients with proposed benefits of a high rate of node identification and pathologic upstaging.³⁶The technique involves either in vivo injection of 0.5–1 cc of isosulfan blue dye subserosally at the periph- ery of the tumor (node visualization within 30–60 seconds), or ex vivo injection of 1–2 cc in a similar manner after the bowel has been resected.³⁵Subsequent evaluation of the technique, including some modifications, has demonstrated false- negative rates approaching 60%, and limitations in rectal cancers.^36–38

There are several concerns that restrict routine implemen- tation of sentinel node assessment in colorectal cancer. First, there is no consensus of opinion regarding the prognostic sig- nificance of micrometastatic lymph nodes in colorectal cancer, particularly those identified by immunohistochemistry

or polymerase chain reaction.^39–45Second, the relatively high false-negative rates and/or lack of node visualization men- tioned previously, limit the confidence in restricting micro- sectioning and use of special stains to the group with stained nodes. Finally, there is insufficient evidence that the technique is sufficiently accurate to alter the extent of surgical resection.⁴⁶Before sentinel node assessment can be routinely recommended, two hurdles must be overcome: 1) provision of incontrovertible evidence that micrometastatic disease identified by any technique correlates with survival; and 2) that the survival rates can be favorably impacted by an adjuvant chemotherapy regimen. Therefore, at the present time, routine lymph node mapping cannot be recommended.

Outcome of Colectomy for Colon Cancer

In general, the operative outcome and long-term survival after resection of curable colon cancer parallels the TNM and Dukes’ stage (A1, well above 90%; B2, 65%–90%; C3, 45%–75%) which may be modulated by adjuvant chemotherapy.^47,48The risk of locoregional recurrence after colectomy is a rare occurrence and should be less than 5%.^49–51However, the impact of the surgeon’s experience and the associated expertise of the institution have recently been found to have a profound effect on outcome. High-volume surgeons, particularly those at high-volume institutions, have demonstrated significantly lower perioperative complications and an improved survival after colectomy for colon cancer.^52–55 A colectomy for palliation should rarely be performed and only in patients with life-threatening comorbidities or advanced incurable disease. Local extension of colon cancer may be treated with chemoradiation initially to allow eventual resection and primary anastomosis.

In addition to experience, the overall surgical approach to management of margins and extent of resection has a signifi- cant effect on outcome after colon cancer resection. The margins to be considered included proximal and distal bowel margins, radial margins, and extent of mesenteric resection which encompasses the nodal resection and proximal vascular ligation. The adequacy of proximal and distal bowel margins is primarily defined by the vascular ligation and hence the adequacy of vascular supply to the intended anastomotic segments. Although not clearly defined, it is generally agreed that 5 cm proximal and distal bowel margins are sufficient to allow resection of mural tumor spread. Grinnell originally evaluated the patterns of mural spread of tumor in the colon via lymphatics and found no instance of spread greater than 4 cm in the most advanced cases.⁵⁶More recent data would suggest that mural tumor migration is rarely greater than 2 cm either proximal or distal to the palpable tumor edge.⁵⁷ Similarly, there is no need to resect any specific amount of terminal ileum, other than defined by vascular supply because mural spread to the ileum is a very rare event. Vascular ligation is generally performed at the origin of the primary feeder

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vessel to a colonic segment. For resection of the right colon and transverse colon, the debate is relatively moot because of the constraints of the arterial origin of the right colic and middle colic arteries. Ligation for left-sided resections has been debated, primarily in sigmoid or anterior resections because ligation of the IMA may be performed at the aorta, or just distal to the left colic artery takeoff. A report from St. Marks assessed this issue in 1370 patients and found that survival was equivalent for all stages for the ligation options except for the most advanced node positive cases who fared worse with ligation at the aorta.⁵⁸This counter-intuitive finding was more likely related to the higher stage of patients identified by the wider lymphatic resection. A comparison of left hemicolectomy and segmental colectomy (ligation of the IMA versus more distal) by the French Association for Surgical Research could not discern either a different survival rate or pattern based on the ligation or resection performed.⁵⁹ Jagoditsch et al.⁴⁷demonstrated the benefits of careful surgical technique which resulted in a complete resection of all tumor (R0).⁴⁹ Their data demonstrated an operative mortality of 1.3% and a 5-year survival rate of 71.8% for curative operations in Stage I–III disease.

Summary

Surgery for colonic cancer has been increasingly better defined and the data clearly support the benefits of wide mesenteric resection, clear radial margins, and resection of adherent adjacent organs. Although the precise level of proximal vascular ligation may remain debatable, it is equally clear that the major trunk vessel and the entire sup- porting mesentery should comprise the specimen. Attention to surgical detail coupled with improved perioperative care strategies are essential to minimizing operative morbidity and mortality.

Appendix: Practice Parameters for Colon Cancer

Prepared by The Standards Practice Task Force, The American Society of Colon and Rectal Surgeons

Daniel Otchy, MD, Neil H. Hyman, MD, Clifford Simmang, MD, Thomas Anthony, MD, W. Donald Buie, MD, Peter Cataldo, MD, James Church, MD, Jeffrey Cohen, MD, Frederick Dentsman, MD, C. Neal Ellis, MD, John W.

Kilkenny III, MD, Clifford Ko, MD, Richard Moore, MD, Charles Orsay, MD, Ronald Place, MD, Janice Rafferty, MD, Jan Rakinic, MD, Paul Savoca, MD, Joe Tjandra, MD, Mark Whiteford, MD

I. Diagnostic evaluation II. Preoperative assessment

Guideline—Preoperative, carcinoembryonic antigen level should be obtained. Level of evidence (Class II, Grade A)

Guideline—Evaluation with preoperative CT scanning of selected patients is indicated and routine preoperative CT scanning is optional. Level of evidence (Class II, Grade B)

Guideline—Routine performance of preoperative chest X-rays is acceptable. Level of evidence (Class III, Grade C)

III. Preparation for operation A. Informed consent

Guideline—Informed consent should be obtained preoper- atively. Level of evidence (Class III, Grade C)

B. Mechanical bowel preparation

Guideline—Mechanical bowel preparation is nearly uni- versally used in elective surgery. Level of evidence (Class II, Grade A)

Guideline—Outpatient bowel preparation is generally safe and cost effective. Level of evidence (Class II, Grade A)

C. Prophylactic antibiotics

Guideline—Prophylactic antibiotics are recommended for patients undergoing colon resection. Level of evidence (Class I, Grade A)

D. Blood cross-match and transfusion

Guideline—Blood transfusion should be based on physiologic need. Level of evidence (Class III, Grade C)

E. Thromboembolism prophylaxis

Guideline—All patients undergoing surgery for colon cancer should receive prophylaxis against thromboembolic disease. Level of evidence (Class I, Grade A)

IV. Operative issues A. Operative technique

Guideline—The extent of resection of the colon should correspond to the lymphovascular drainage of the site of the colon cancer. Level of evidence (Class II, Grade B)

B. Synchronous colon cancer

Guideline—Synchronous colon cancers can be treated by two separate resections or subtotal colectomy. Level of evidence (Class II, Grade B)

C. Contiguous organ attachment

Guideline—Colon cancers adherent to adjacent structures should be resected en bloc. Level of evidence (Class II, Grade A)

D. Synchronous resection of liver metastases

Guideline—Resection of synchronous liver metastases may be reasonable to perform at the time of the initial colon resection. Level of evidence (Class III, Grade B)

E. Role of oophorectomy

Guideline—Bilateral oophorectomy is advised when one or both ovaries are grossly abnormal or involved with contiguous extension of the colon cancer. However, prophylactic oophorectomy is not recommended. Level of evidence (Class II, Grade B)

F. Role of laparoscopic resection

Guideline—Relative merits of laparoscopic versus open resection for colon cancer remain unproved at this time. Level of evidence (Class II, Grade B)

V. Operative issues—emergent A. Obstructing colon cancer

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Guideline—Patients with an obstructing right or transverse colon cancer should undergo a right or extended right colectomy. A primary ileocolic anastomosis can be performed in the appropriate clinical setting. Level of evidence (Class II, Grade C)

Guideline—For the patient with a left-sided colonic obstruction, the procedure selected should be individualized from a variety of appropriate operative approaches. Level of evidence (Class II, Grade C)

B. Colonic perforation

Guidelines—The site of a colonic perforation caused by colon cancer should be resected, if at all possible. Level of evidence (Class III, Grade C)

C. Massive colonic bleeding

Guideline—Acutely bleeding colon cancers that require emergent resection should be removed following the same principles as in elective resection. Level of evidence (Class III, Grade C)

VI. Staging of colon cancer

Guideline—Colon cancers should be staged using the TNM staging system. Level of evidence (Class II, Grade B)

Guideline—To be properly evaluated, one should strive to have a minimum of 15 lymph nodes examined microscopi- cally. Level of evidence (Class II, Grade B)

VII. Adjuvant therapy A. Chemotherapy

Guideline—Postoperative adjuvant systemic chemotherapy has a proven benefit in Stage III colon cancer and may be ben- eficial in certain high-risk Stage II patients. Level of evidence (Class I, Grade A)

B. Immunotherapy

Guideline—The value of immunotherapy for colon cancer is undetermined. Its use is recommended within the setting of a clinical trial. Level of evidence (Class II, Grade C)

C. Intraperitoneal/Intraportal Chemotherapy

Guideline—Intraperitoneal and intraportal infusions of chemotherapy are recommended only in the confines of a clinical trial. Level of evidence (Class II, Grade C)

D. Radiation therapy

Guideline—The role for radiation therapy in colon cancer is limited. Level of evidence (Class II, Grade C)

Reprinted from Dis Colon Rectum 2004;47:1269–1284.

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