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Les symptômes du cancer du côlon peuvent passer inaperçus pendant plusieurs années et dans la plupart des cas, la maladie se développe très lentement.

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Le côlon est l’endroit où le corps stocke les déchets et fait partie du système digestif humain. Le rectum est situé à l’extrémité du côlon. Le côlon et le rectum forment ensemble un long tube souvent désigné comme le gros intestin.

Qu’est-ce que le cancer du côlon ?

Les excroissances qui se forment sur le côlon, l’intestin, l’anus et le rectum sont dans la plupart des cas bénignes (polypes) mais peuvent parfois dégénérer pour devenir un cancer ou tumeur. Les polypes sont enlevés en utilisant une procédure chirurgicale appelée une coloscopie et ne sont pas considérés comme un risque majeur pour votre santé (sauf si elles ne sont pas traitées).

La plupart des polypes bénins présentent le risque de devenir cancéreuses (malignes) si elles ne sont pas enlevées. On pense que la plupart des cas de cancer du côlon se sont formées et développées à partir de polypes non traités.

Le cancer du colon et le cancer du rectum font partie du cancer colorectal. Ils sont connus pour envahir d’autres organes et tissus et pour se propager à d’autres parties du corps avec la formation de nouvelles cellules cancéreuses.

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I – Le pronostic du cancer colique ne connaît pas d’amélioration significative. Les lésions sont longtemps asymptomatiques et leur traduction clinique correspond a des formes trop évoluées avec un essaimage lymphatique fréquent qui réduit les possibilités thérapeutiques curatives. En fait, si le diagnostic est fait au stade A de la classification de DUKES, la survie à 5 ans est supérieure à 90 % Au stade B, elle est réduite d’un tiers (60 a 70 % de survie). Au stade C elle est encore inférieure de moitié au stade précédant (30 à 35 %) .

II – La prévention du cancer concerne le traitement adapté des états précancéreux: adénomes, tumeurs villeuses, et avant tout adénomatose recto-colique dont la dégénérescence est inéluctable.

III – Le dépistage du cancer a pour ambition de le diagnostiquer au stade superficiel, muqueux, qui donne aux malades un excellent pronostic. La prévention et le dépistage sont souvent intriqués car la découverte d’une lésion maligne peut être associée à la mise en évidence d’un adénome, dont l’exérèse peut être endoscopique dans le même temps.

IV – La stratégie des explorations de détection varie en fonction des circonstances:

le dépistage de masse peut utiliser le test  » Hémocult « , en sachant que sa négativité ne doit jamais faire éliminer le diagnostic de cancer.
Les patients ne présentant aucun trouble, mais consultant après avoir été sensibilisés par une campagne d’information, peuvent être explorés initialement par une coloscopie  » courte  » ou par sigmoïdoscopie.
Les patients présentant un symptôme intestinal évocateur ou plus banal doivent bénéficier d’une coloscopie complète.
Les sujets a risque élevé doivent être examinés en coloscopie une fois par an.

Principes du traitement du cancer du côlon :

Le traitement du cancer colique est essentiellement chirurgical. Il a pour but l’exérèse du segment colique porteur de la tumeur associée a un curage du territoire lymphatique correspondant, mésentérique supérieur ou inférieur, qui entraînent les ligatures vasculaires les plus haut situées possibles sur les axes artériels: a l’origine de l’artère mésentérique inférieure pour une lésion gauche, au contact du bord droit de l’artère mésentérique supérieure pour une lésion droite. En dehors des formes compliquées, cette exérèse est suivie d’un rétablissement de continuité par anastomose iléo-colique, colo-colique, colo-rectale, fonction du niveau de l’exérèse.
L’efficacité de la chimiothérapie actuellement disponible est très limitée, et, appliquée a doses efficaces, elle expose a une toxicité, surtout médullaire, dont le risque est parfois supérieur aux espoirs qu’on peut en attendre,

I – Traitement des cancers coliques non compliqués

Toute exérèse colique doit être précédée par une préparation adaptée, générale et locale. . générale avec étude pré opératoire des grandes fonctions et correction des désordres éventuels . locale avec pour objectif d’obtenir la vacuité du colon par – un régime alimentaire sans cellulose associé à une administration d’huile composée per os et a des lavements évacuateurs pendant 3 a 5 jours – ou une ingestion 24 a 48 H avant l’intervention de potion laxative (3 litres de P.E.G.).

L’intervention comporte un premier temps d’exploration appréciant le siège, l’extension locale, l’existence d’éventuelles métastases a distance ganglionnaires ou hépatiques C’est alors seulement que le type d’intervention adéquate pourra être décidé

soit exérèse curative, carcinologiquement complète. éventuellement associée à la résection d’une métastase unique hépatique dans le même temps ou ultérieurement.
soit exérèse palliative, de propreté, en cas de dissémination incontrôlable chirurgicalement.
soit devant une tumeur encore plus évoluée inextirpable, en cas de sténose serrée et en fonction de la localisation, une simple colostomie d’amont ou une dérivation interne court-circuitant la lésion, typeanastomose iléo-transverse en cas de tumeur colique droite inextirpable.

1) Cancer du côlon droit.

L’intervention carcinologique comporte une exérèse emportant la fin de la dernière anse iléale, et le colon jusqu’au tiers droit du transverse, avec ligature première des vaisseaux droits coliques supérieurs, coliques moyens, et ileo-caeco-colo-appendiculaires au contact de l’axe mésentérique supérieur. Le rétablissement de continuité est effectué dans le même temps avec anastomose iléo-transverse termino-terminale ou termino-latérale

2) Cancer du côlon transverse

Lorsqu’il siège sur le tiers droit du transverse, la tumeur est traitée chirurgicalement selon les mêmes principes que le cancer du colon droit
Au niveau des 2/3 gauches, le traitement comporte une résection segmentaire emportant environ 10 cm de colon de part et d’autre de la lésion, et tout le mésocolon et sa vascularisation en regard jusqu’au niveau de sa racine au contact du pancréas.

3) Cancer du côlon gauche

a) En présence d’un cancer du colon descendant ou du sigmoïde, l’intervention à visée carcinologique impose une ligature première des vaisseaux mésentériques inférieurs au niveau de l’origine de l’artère, sur la face antérieure de l’aorte, en regard de D3. L’exérèse comporte une résection colique segmentaire passant en amont à 10 cm des limites de la tumeur, et en aval au niveau de la jonction recto-sigmoïdienne, en associant un curage ganglionnaire mésentérique inférieur. Le rétablissement de la continuité est effectué par anastomose colo-rectale termino-terminale.

b) Devant une tumeur de l’angle gauche, 11 est licite de préserver l’axe mésentérique inférieur, de lier les vaisseaux coliques supérieurs au niveau de l’origine de l’artère, d’effectuer une résection segmentaire emportant 10 cm de part et d’autre de la lésion, et de terminer l’intervention par une anastomose colo-colique termino-terminale.

II – Traitement des cancers du côlon non compliqués

Il est de réalisation plus difficile, avec des suites opératoires moins favorables et un pronostic à distance plus sombre, chez des patients dont la préparation colique n’a pu être effectuée.

1) Occlusion

Apres que son siège exact sur le cadre colique ait été précisé par un lavement opaque, l’intervention est réalisée après une courte période de réanimation associant aspiration gastrique et rééquilibration hydro-électrolytique .

a) Sur le colon droit, une occlusion récente peut être traitée par une résection suivie d’anastomose iléo-transverse dans le même temps.

b) Sur le colon gauche, où le siège est le plus souvent sigmoïdien, la meilleure attitude dans un premier temps est d’effectuer une colostomie latérale de proche amont par voie élective, en réalisant 4 a 6 semaines plus tard l’exérèse carcinologique de la lésion en cause sur un colon correctement préparé.

La mortalité post-opératoire d’une colectomie segmentaire suivie d’anastomose sur un colon préparé est de 0.5 à 1% dans un service de chirurgie digestive spécialisée.

III- Surveillance post-opératoire ultérieure

Tout malade opéré d’un cancer colorectal doit bénéficier d’une surveillance attentive et régulière.

Une coloscopie doit être effectuée tous les ans au cours des 5 premières années pour rechercher d’éventuels adénomes ou une récidive néoplasique. Dans l’hypothèse où le caractère sténosant de la tumeur n’aurait pas permis une exploration endoscopique pré opératoire complète du cadre colique, le premier contrôle doit être demandé 2 a 3 mois après la résection d’anastomose.
Une échographie hépatique, à la recherche de métastases, s’impose tous les 6 mois pendant 2 ans puis tous les ans. A condition d’avoir recours à un opérateur entraîné, cet examen est plus performant pour les petites lésions que la tomodensitométrie.
Une radiographie pulmonaire sera demandée au même rythme que l’échographie
Le dosage de l’Antigène Carcino-Embryonnaire n’a d’intérêt dans la surveillance post-opératoire que dans des conditions précises qui associent: . un taux élevé pré opératoire . une exérèse carcinologique complète . un retour a la normale post-opératoire (en 2 a 6 semaines). Dans ces conditions. la réapparition d’un taux élevé doit faire évoquer une récidive tumorale qui doit entraîner les explorations qui pourront l’affirmer, y compris une nouvelle laparotomie.

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