Case presentation1. PARTICULARS OF THE PATIENT:Name: Ayub Ali Date Admission: 29/08/09Father’s name: Late Abdul Ali Hospital : SBMCHAge: 65 years. Department : SU-ISex: male. Ward : 11Marital status: married . Bed : 16Religion: Islam.Occupation: farmerSocial status : PoorAddress: Kawer Char Barisal Sadar Dist- Barisal
Case presentation2. PRESENTING COMPLAINTS : Weakness for 6 months Feeling of incomplete defecation for 3 months Pain or discomfort during defecation for same duration Per rectal bleeding for 3 months
Case presentation3. HISTORY OF PRESENT ILLNESS: According to the statement of the patient he was quite well 6 months back. Since then he developed nausea and found himself unwilling to do any daily activities due to unusual weakness. He went to village doctor who advised him some vitamin tablets but these were not very fruitful to overcome his weakness or nausea. Then after 3 months he noticed passing of hard stool followed by small amount of bleeding at end of defecation.
Case presentation3. HISTORY OF PRESENT ILLNESS: He ignored this bleeding and thought this may be due to constipation. But after few days he felt abdominal cramp which made him to get up early in the morning due to urge for defecation but only some amount of muciod watery stool came out which could not satisfy his defecation urge, as well as passage of rectal bleeding didn’t stop. And for last 15 days rectal bleeding worsened so he came to our hospital for better management.
Case presentation4. HISTORY OF PAST ILLNESS: HTN.5. PERSONAL HISTORY: Diet habit : He took high fibre and roughage Vegetables almost daily Less animal fat Red meat usually once in a month Nonsmoker Nonalcoholic .6. FAMILY HISTORY: None of His family members were suffering from this type of disease
Case presentation7. DRUG HISTORY: Anti-hypertensive: Tenoren Amdocal Syp. Antacid8. HISTORY OF IMMUNIZATION: Not Completed.
Case presentation9. GENERAL EXAMINATION: Appearance: ill looking Anemia : present Height : 5 ft. 2 inches Jaundice : absent. Weight : 50 kg. Edema : absent. Body build : Below average. Pulse : 80/min. Decubitus : on patient’s choice. B.P :160/100mm/Hg. Dehydration: absent Temp. : 98`F Enlarged lymph node: absent. Nutrition : below average. RR : 22 breaths/min.
Case presentationThe Abdomen cont ...B. PALPATION: 1. SUPERFICAL PALPATION: Local temperature : not raised. Tenderness : absent. Muscle guard/Rigidity : absent 2. DEEP PALPATION: Liver : not enlarged. Gallbladder : non palpable. Spleen : non palpable . Kidneys : kidneys were nonballotable.
Case presentationThe Abdomen cont ...C. PERCUSSION : Percussion note : Normal.D. AUSCULTATION : Bowel sound : normal.E. DRE FINDINGS : an annular growth encircling the whole circumference of the rectum which was hard in consistency with irregular margin associated with multiple small polypoid lesion around the growth which seems to be fixed with the surrounding muscles and involving the anal sphincter was found about 3 cm from the anal verge.
Case presentation11. OTHER SYSTEMS EXAMINATION : Cardiovascular system : normal. Respiratory system : normal. Nervous system : normal. Genito Urinary System : normal.
Case presentation12. CLINICAL DIAGNOSIS: Carcinoma of rectum
Case presentation13. INVESTIGATIONS : A. COMPLETE BLOOD COUNT: Total Count : 8000/ cmm of blood Differential Count : Neutrophil – 57% Lymphocyte count – 37% Mono cyte- 01% Eosinophil – 05% Basophil – 00% Hb% : 50%. ESR : 40 mm in 1st hour. (anaemia was corrected by 2 unit blood transfusion) B. BLOOD FOR RBS AND SERUM CREATININE: RBS – 310 mg/dl 112 mg/dl after control with inj. insulin Creatinine – 0.9mg/dl
Case presentationInvestigations cont … C. URINE FOR RME: Color – Straw Appearance – Clear Albumin – absent Epithelial cells – (2-4) / HPF RBC – Nil Pus Cells – (1-2) /HPF D. PLAIN X-RAY OF CHEST P/A VIEW: Normal
Case presentationInvestigations cont … F. USG OF WHOLE ABDOMEN (01/09/2009) Liver: An echogenic area with surrounding halo is seen in posterior superior quadrant of right lobe of liver near gall bllader. All other viscera were normal and no lymphadenopathy or ascites Impression: suggestive of SOL of liver. most possibly 2ndary
Case presentationInvestigations cont … G. Proctoscopic biopsy: Proctoscopic biopsy was taken from the annular rectal growth and after proper preservation and labelling was sent for hislogical examiantion. Histological examination revealed – adenocarcinoma, moderately differentiated. ( Colonoscopy & CEA – not done)
Case presentation15. TREATMENT Plan Of Treatment : Abdominoperineal excision Ratinonale: The growth was 3 cm from the anal verge and involving the sphincter Pre Operative Preparation : The pt. was made fit for general anesthesia with proper diet, nutrition , blood transfusion and adequate glycaemic control with inj. insulin and control of BP with anti- hypertensive and required investigations were done. Two units of fresh human blood were arranged for operation.
Case presentation15. TREATMENT Bowel preparation: NPO from 10 pm (day before surgery) Inf. Hartman’s solution 1000 ml: IV @ 10 drop/min Inj. Ciprofloxacin 500 mg: IV bd Inj. Metronidazole 400 mg: IV tds Inj. Mannitol: 250 ml orally at 5pm 125 ml orally if necessary at 6 pm Enema Simplex: at 10 pm (day before surgery) at 7 am ( on day of surgery) Consent :1. An informed written consent was taken from the pt. and his wife for abdomenoperineal excision along with permanent colostomy in left iliac fossa under general anesthesia.2. Patient and his wife was briefed about management of colostomy.
Case presentationTreatment ( Surgical management ) cont … OPERATION NOTE : Venue : General OT in SBMCH, Barisal. Date : 25/10/2009. Time : 11:30 am. Indication : carcinoma rectum. Name of operation : abdomenoperineal excision with permanent end colostomy. Name of anesthesia : GA with endotracheal intubation. Name of Surgeon : Prof. A M S M Sharfuzzaman. FCPS, MRCS (Edin) Dr. Zahurul Haq FCPS (surgery) Assistant Professor, Surgery
Case presentationTreatment ( operation note ) cont … Position: Trendelenburg lithotomy position (with urinary catheter in situ) Incision: Abdominal surgeon – made a midline incision Perineal surgeon – made an elliptical incision between the coccyx and the central perineal point, around anus.
Case presentation15. TREATMENT Procedure and findings : With all aseptic precaution abdominal surgeon opened the abdomen through a midline incision. Liver and peritoneal cavity was assessed for any metastasis. Which was not found. So decision for curative Total mesorectal excision was taken Coils of small intestine was packed using mops to keep them away from the pelvic cavity. Retractors were used for proper exposure and sigmoid colon was freed by dividing the peritoneal reflection on the left side. The sigmoid colon was mobilized to the midline on its mesentry, and the left ureter and testicular vessels were identified and secured.
Case presentationTreatment ( operation note ) cont … The mesocolon was divided at the site of proposed division of the colon and the inferior mesenteric artery ligated and divided distal to the first sigmoidal branch. Then the sigmoid colon at this point, is cut in between the intestinal clumps. Peritoneal fold over the rectosigmoid junction is divided to make it free. Middle rectal artery was ligated and divided. Median sacral artery were also secured. Sigmoid colon and rectum were freed from the pelvic cavity by both sharp and blunt dissection preserving the nerves of sacral plexus.
Case presentationTreatment ( operation note ) cont … The perineal surgeon closed the anus with purse-string sutures using no. 1 cutting body silk. An elliptical shaped incision around the anus through the transverse perineal muscle anteriorly and levator ani muscle posteriorly and keeping the dissection line away from the prostate and urethra through Denonviller’s fascia. The left forefinger was insinuated into the levator ani, which was divided lateral to the finger, first on one side then on another side. Dissecting the Waledeyer’s fascia by diathermy and scissors, then contact was made with the abdominal surgeon. The apex of the skin anterior to the anus was grasped by artery forceps acting as a retractor. The wound was deepened by dissection by diathermy, scissors and gauge. When the catheter within the membranous urethra was felt, a plane of cleavage was formed between the rectum and prostate.
Case presentationTreatment ( operation note ) cont … Denonviller’s fascia was divided after which the rectum was separated from the prostate. The abdominal surgeon freed the rectum from pelvic cavity. Whole of the anus, rectum and part of the sigmoid colon was drawn downwards and removed through the perineal wound. Haemostasis was done using diathermy, ligation and hot mopping. The perineal muscle was closed in layers with 1/0 round body vicryl. Skin was closed with 2/0 cutting body silk. A drain was applied in the peritoneal cavity through the right ischeorectal fossa.
Case presentationTreatment ( operation note ) cont … A permanent end colostomy was made 2.5 cm above the left spino-umbilical line. Peritoneal defects were sutured with 1/0 round body catgut. Abdomen was closed in layers. Peritoneum sutured by 1/0 catgut ,Linea alba by no. 1 prolene and skin by 2/0 silk. Sterile dressings were placed on the abdominal and perineal wound
Case presentationTreatment ( operation note ) cont …16. Postoperative period: NPO for 48 hours then food was given orally IV fluid for 48 hours IV antibiotic for 5 days IM analgesic for 48 hours then switched to oral formulation Colostomy was managed by colostomy bag Catheter – removed on 5th POD Perineal wound infection was noticed on 6th POD, stitches were removed , and wound was managed by Seitz bath
Figure showing :midline incision markcolostomy bag in place (coveringThe colostomy in left iliac fossa)
Figure showing:Gap in the perineal woundWhich was later on managed bySeitz bath
Case presentationTreatment ( operation note ) cont …18. DISCHARGE AND ADVICE : Patient was advised to contact with radiotherapy department on 15th post operative day for further oncological surveillance.