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Kirurgisk behandling av endetarmskreft uten fjernmetastaser

Kirurgisk behandling av endetarmskreft uten fjernmetastaser

Sist oppdatert: 20.12.2023
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Utgiver: Helsedirektoratet
Versjon: 1.0
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Anbefalinger 

  • Onkologisk er karavsetning med bevaring av arteria colica sinistra adekvat i de fleste tilfeller, og funksjonelt fordelaktig (evidensgrad B)
  • Total mesorektal eksisjon (TME) er den anbefalte kirurgiske teknikk ved operativ behandling av endetarmskreft (evidensgrad C). Ved tumor i øvre del av rektum er PME likeverdig forutsatt 5 cm reseksjonsmargin i mesorektum distalt for tumor.
  • Hos ubestrålte med en svulst distalt i endetarmen er en distal margin ned mot 1 cm adekvat. Hos bestrålte synes ikke en kort pDRM være en risikofaktor (evidensgrad C)
  • Ved affeksjon eller gjennomvekst av mesorektal fascie må inngrepet utvides med en bloc reseksjon av affiserte organer/strukturer (evidensgrad C)
  • Lavrisiko T1 cancere kan behandles med endokospisk reseksjon/TEM/TAMIS (evidensgrad B).
  • For høyrisiko distal pT1 svulst, bør kompletterende kirurgi tilbys etter 6 uker, men adjuvant kjemoradioterapi kan være et alternativ.
  • Pasienter med overveiende sannsynlige lymfeknutemetastaser på bekkenveggen bør tilbys preoperativ strålebehandling, og ved liten respons bør de vurderes for påfølgende kirurgi på bekkenveggen da det gir bedre lokal kontroll.
  • Antibiotika- og trombolyseprofylakse skal gis. Se her for anbefalt antibiotikaprofylakse.

Tumor med distale begrensning 15 cm eller mindre fra ytre analåpning vurdert med stivt rektoskop betegnes som rektumtumor. Det er viktig å være oppmerksom på at både fleksibel skopi og avstandsangivelse ved kolografi ofte gir lengre avstander.

Alle pasienter med endetarmskreft skal i utgangspunktet vurderes med tanke på kirurgi i radikal eller palliativ hensikt, med mindre den medisinske tilstanden er slik at pasienten ikke tåler det eller sykdommen er kommet så langt at palliativ reseksjon ikke er hensiktsmessig. Alle pasienter skal vurderes av et tverrfaglig team for å avklare multimodal behandling. Kirurgen må ved preoperativ samtale informere om muligheten for vanlige postoperative komplika­sjoner, risiko for anastomosesvikt og forventet funksjonelt resultat ved mulige operasjons­metoder. Endelig valg av operasjonmetode må avgjøres i samråd med pasienten ut fra tumors størrelse, lokalisasjon, komorbiditet og pasientens ønsker. Det pålegger den enkelte avdeling å organisere pasientforløpet på en måte hvor pasientens samvalg og informasjon blir ivaretatt i møte mellom pasient og lege i god tid før inngrepet.

Det er meget sjelden behov for akutt kirurgi ved endetarmskreft, men Hartmanns operasjon, avlastende sigmoideostomi eller total kolektomi og ileostomi kan være aktuelle behandlingsformer ved stenoserende kreft. Ved stenose i øvre del av endetarmen kan midlertidig stent (Gargallo et al., 2019) være et godt alternativ, men det krever erfaring med metoden.

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