Discussion on the Pathology and Treatment of Carcinoma of the Colon

Mr. Rodney Maingot: During recent oyears there have been many noteworthy advances in the management of patients suffering from carcinoma of the colon. Not only is the eradication of the lesion now possible in the majority of such cases, but the operation is associated with a low death-rate. When we compare the prognosis of cancer in the colon with that occurring in other parts of the body, it is obvious that the colon represents one of the most favourable sites for cure. Before the present war the resection-fate was 50 to 60%; to-day it is about 80%, even excluding the excellent operability-rates of R. Cattell (1943) 84%, A. W. Allen (1943) 91%, and 0. Wangensteen (1943) 93%. The inoperable case is fast becoming a rarity. Until about 1938 radical resection of the colon for cancer gave in the hands of most surgeone a mortality of approximately 20%. Thus in a series of 3,000 cases collected by Ochsner and DeBakey (1939) there were 422 deaths 14o/. During the last five or six years, however, there'has been a most gratifying and dramatic fall in the operative mortality which coincides w"ith a period in which, owing to improved pre--and post-operative measures and' safer antesthesia, surgeons have shown greatly increased courage, tenacity of purpose and skill in the eradication of malignant processes of the bowel. There are indeed now few cancerous lesions within the abdomen which the expert and determined surgeon cannot extirpate. He has learned that resection affords the maximum degree of palliation; that multiple resections may on occasion yield a brilliant cure; and that, even in the presence of hepatic metastases, if the growth is capable of removal, this should be unhesitatingly performed. At the Mavo Clinic between 1907 and 1938 there were 8.000 cases of excision of the colon for carcinoma with an 'operative mortality of 18.5%. In 1942, however, there were 879 patients who were subjected to resection and the death-rate was only' 5-1%. A standard of excellence has been set for us by Gordon-Tayloir who up to April 1941 performed 138 exteriorization-resection operations for cases of carcinoma of the colon with onlv seven deaths-a mortality of about 5%. The life-expectancy following adequate removal of carcinoma of the colon is relatively good, and many clinics can claim 40 to 50% of five-year cures. Cattell (1944) states that 55% of his patients with carcinoma of the colon who had undergone resection showed no evidence of recurrence for five to nine years. Dixon's figures (1944) are even betterfive-year cures: right colon 72%; descending colon 63%; and sigmoid colon 44%. His findings support the truth that the prospect of cure following excision of the colon decreases from the caccum through the more distal segmenis. Among the many factors responsible for the encouraging advances in this field I would mention: (1) Earlier recognition of carcinoma of the colon due to improved radiological methods; (2) a better understanding among surgeons of the importance and the means of maintaining fluid, vitamin C, electrolyte, and protein balance before and after operation; (3) the treatment of shock by plasma and whole-blood transfusions; (4) the universal acceptance of the principle that a primary resection of the colon should never be performed in the presence of acute or subatute obstruction; (5) the measures now adopted in the immediate preand post-operative phases for ensuring adequate decompression of the intestine by means of an indwelling intestinal tube or Miller-Abbott tube; (6) the control of infection by means of sulphonamidc drugs and penicillin, and the mitigation of bacterialactivity within the bowel bv the administrat-ion of sulphasuxidine in . adequate dosage before and after operation; (7) improved anaesthetict methods which permit the surgeon to be more deliberate and painstaking in his operative procedures; (8) the more general utilization of stage operations for resectable growths of the large bowel.