The treatment strategy for each patient is defined by a tumour board made up of gastrointestinal oncologists, chemotherapy specialists, radiologists and pathologists. This approach makes it possible to apply all available forms of anti-tumour therapy in the most rational way, drawing on European and American registry databases, the experience of evidence-based medicine and the mandatory recommendations of the German and international oncology societies on the treatment of bowel tumours. Nevertheless, the principal treatment for bowel cancer remains surgery, covering the full spectrum of interventions on the abdominal and pelvic organs and the rectum. The extent of surgery is determined by the spread of the tumour. All operations can be divided into:
- simple (standard resection of part of an organ without extended lymph node dissection);
- extended (removal of an organ or part of it together with its lymphatic system and the surrounding fatty tissue);
- combined (removal of another organ or part of it that is involved in the tumour process);
- simultaneous (combining tumour removal with an intervention for another concomitant condition).
By purpose, operations are divided into:
- diagnostic (to verify the diagnosis);
- symptomatic (to relieve symptoms that threaten the patient's life or impair its quality);
- radical (complete removal of the visualised tumour in the absence of metastases);
- palliative (incomplete removal of all lesions in order to reduce the tumour burden and then apply other treatment methods).
Operations on the liver and biliary tract
- enucleation of colorectal cancer metastases in the liver;
- radiofrequency ablation of liver metastases (both percutaneous under ultrasound or CT guidance and intraoperative);
- atypical liver resections;
- right hemihepatectomy;
- left hemihepatectomy;
- Monastyrsky operation (various modifications);
- cholecystectomy, including laparoscopic.
Operations on the small bowel and colon
- small bowel resections;
- colostomy, ileostomy (including laparoscopic);
- right hemicolectomy (including laparoscopic)
extended right hemicolectomy (including laparoscopic); - resection of the transverse colon (including laparoscopic);
- left hemicolectomy (including laparoscopic)
extended left hemicolectomy (including laparoscopic); - sigmoid colon resection (including laparoscopic)
total and subtotal colectomy (including laparoscopic).
Operations on the rectum
- anterior rectal resection (including laparoscopic)
Hartmann's procedure (including laparoscopic); - abdominoanal rectal resection with formation of a colonic pouch and coloanal anastomosis (including laparoscopic);
- coloproctectomy (including laparoscopic);
- Quenu-Miles abdominoperineal excision of the rectum (including laparoscopic, with repair of the perineal wound using the gluteal muscle or a Permacol graft);
- supralevator and infralevator pelvic exenteration
transanal endoscopic microsurgical removal of a rectal tumour.
Reconstructive operations
- restoration of bowel continuity after obstructive resections of the colon and rectum (in some cases with formation of a pouch)
closure of a transversostomy or ileostomy.
Germany's gastroenterology clinics have extensive experience in removing giant tumours of the abdominal cavity and retroperitoneal space. Patients are treated at an interdisciplinary level.
It is worth noting that in coloproctology units around 90 % of operations on the colon and rectum are performed laparoscopically, that is, without a long incision in the anterior abdominal wall. This helps reduce pain, prevents the development of adhesions, speeds up the patient's rehabilitation and gives a good cosmetic result.
If the tumour is located in the distal rectum, the surgeons try to preserve the rectal sphincter apparatus and the anus, to avoid damaging the innervation of the pelvic organs and, in men, to preserve potency. To improve the functional results of such operations and to preserve the reservoir and evacuation function of the rectum as well as continence, a pouch is formed from the pulled-through bowel and the external sphincter is preserved. For these surgeons, the patient's quality of life matters no less than the oncological soundness and radicality of the operation.
Chemotherapy
Before or after surgery, drug therapy (anti-tumour treatment) is started where necessary:
- neoadjuvant chemotherapy (given before surgery to reduce the recurrence rate; in rectal cancer it is often combined with radiotherapy);
- adjuvant chemotherapy (preventive, given after surgery over several months)
Radiotherapy
Modern approaches to the treatment of rectal cancer are unthinkable without radiotherapy. Radiotherapy has now been proven highly effective in rectal cancer when it is used in the neoadjuvant setting (that is, before surgery). Radiation is even more effective in combination with radiosensitising agents (the chemotherapy drug capecitabine, metronidazole and others). Several types of preoperative radiotherapy are used:
classic fractionation regimen with a total radiation dose of 52 Gy with radiosensitisation by capecitabine (in a number of such cases complete tumour regression can be achieved without surgery). Surgery is performed 6 - 8 weeks later;
large-fraction regimen of 5 Gy per fraction daily for 5 days followed by surgery. This regimen more than halves the risk of recurrence;
intraluminal contact radiotherapy (usually combined with external beam radiotherapy). It helps reduce the tumour burden.
Patients with locoregional recurrence of colorectal cancer receive palliative radiotherapy for symptomatic and cytostatic purposes.
It should be noted that radiotherapy is delivered on modern accelerators capable of conformal irradiation (with the formation of a complex radiation field), which makes it possible to minimise complications and unwanted side effects.
