surgery mbbs

1. MANAGEMENT OF
RECTAL CARCINOMA
Presented by: Adithya S
MBBS, Govt Thiruvarur Medical College

2. SURGICAL ANATOMY

3. ● Surgery is the mainstay of curative therapy
● The primary resection consists of rectal resection performed by total mesorectal excision
● Most cases can be treated by anterior resection, with the colorectal anastomosis being achieved with a circular
stapling gun
● A smaller group of low, extensive tumours require an abdominoperineal excision with a permanent colostomy
● Preoperative radiotherapy with or without chemotherapy can be used to down-stage the cancer and reduce local
recurrence
● Adjuvant chemotherapy can improve survival in node-positive disease
● Liver resection in carefully selected patients offers the best chance of cure for single or well-localised liver
metastasis
SURGICAL PRINCIPLES

4. SURGICAL MANAGEMENT
1. Abdominoperineal resection
2. Anterior resection
3. Transanal total mesorectal excision (ta TME)
4. Hartmann’s operation
5. Pelvic evisceration
6. Palliative colostomy

5. SURGICAL MANAGEMENT
ABDOMINOPERINEAL RESECTION
o The sigmoid , descending and upper rectum is mobilised per abdominally .
o Anal canal with perianal and perirectal tissues are dissected per anally .
o Retained colon is brought out as end colostomy in left iliac fossa
o Done through lower mid line incision in lithotomy position .
o Rectum is mobilised posteriorly in avascular plane in front of nerve plane between
mesorectum and sacrum .
o Colon is transected and proximal cut end is fashioned for end colostomy in left iliac
fossa.
o Circumferential incision is placed around the anus.
o Anterior dissection is done to reach above and specimen is removed through
perineal wound.
o Colostomy is created by suturing skin to mucosa using silk / vicryl

6. APR - TYPES
MILES GABRIEL
Abdomen first , perineum later
Synchronised , combined
Perineum first, abdomen later
LLOYD-DAVIES

7. ABDOMINOPERINEAL
RESECTION

8. INDICATIONS
FOR APR
It is the treatment of choice when :
 Mesorectum is involved
 When it is poorly differentiated
tumour
 When nodes are involved.
 It gives adequate clearance

9. SPHINCTER SAVING APR WITH COLOANAL
ANASTOMOSIS
 Done in operable distal rectal tumour in young individuals wherein anal sphincter need
not be sacrificed but adequate oncological tumour clearance can be achieved
 Entire rectosigmoid is removed retaining only the anal sphincter
 Colonic J-pouch or coloplasty reservoir is created in the mobilised descending colon
 Coloanal anastomosis is done per anally using hand sutures under direct visualisation
 Here a permanent colostomy stoma is avoided

10. APR WITH NEO SPHINCTER
RECONSTRUCTION
This is technically difficult with complications
Perineal colostomy is done with gracilis muscle wrap which is made to
produce sphincter like muscle, twitch using an implanted pacemaker

11. COMPLICATIONS OF APR
 Bleeding
 Infection of perineal wound
 Complications of colostomy like prolapse ,
stenosis and infection
 Injury to the urinary system , ureter ,
impotence , urinary incontinence
 Operative mortality < 2%

12. ANTERIOR RESECTION
• It is done in growths located in the mid and upper part of the
rectum , which is well differentiated, small sized and with clear
adequate length for anastomosis after resection.
• It is also called anterior proctosigmoidectomy through abdominal
approach where in the rectum above the peritoneal reflection is
resected with colorectal anastomosis.
• Low anterior resection (LAR) is the resection of rectum below
the peritoneal reflection along with the sigmoid colon , with total
mesorectal excision through abdominal approach and colorectal
anastomosis using circular stapler device ( EEA stapler)

13. CRITERIA FOR
ANTERIOR RESECTION
 Upper and middle third rectal growth
 Above peritoneal reflection
 Well differentiated tumour , < 4cm sized
tumour
 In females , growth 7cm above the anal
verge
 T1 N0 / T2 N0 tumour
 Tumour without lymphatic or venous spread

14. DISADVANTAGES
 Can avoid permanent colostomy
 Sphincter is retained
 More patient acceptance
ADVANTAGES
× Uncertainty of clearance , chances of local
recurrence is high
× Anastomotic leak , infection , stenosis
× LAR syndrome-frequent small bowel movements
causing more frequent stools (can be avoided by
creating reservoir by doing colonic J-pouch or by
doing coloplasty 6cm from the proximal divided
end of colon)

15. TRANSANAL TOTAL MESORECTAL EXCISION (ta TME)
• The trauma of anterior resection can be reduced by undertaking total
endoluminal excision of the rectum
• It builds on the principle of laparoscopic surgery, with an airtight anal device
used to provide transanal insufflation and access for laparoscopic
instruments
• A purse-string suture is placed below the distal level of the tumour and the
bowel wall in incised to enter the mesorectal plane. Dissection then
proceeds using a ‘bottom-up’ approach to accomplish TME
• Ssimultaneously a ‘top-down’ laparoscopic resection is done by an
abdominal operator who mobilises the left colon takes down the splenic
flexure and does some of the upper rectal dissection

16. HARTMANN’S OPERATION
 It is a palliative procedure done is elderly people who are not fit for major surgery
like AP resection and also in locally advanced tumours
 Rectal growth is resected and upper end of rectum is closed completely
 Proximal colon is brought out as end colostomy

17.  It is the removal of rectum with the tumour , all the lymph nodes , urinary bladder, fat, fascia,
uterus, vagina, with colostomy and urinary diversion
PELVIC EVISCERATION (BRUNSCHWIG’S OPERATION)

18. PALLIATIVE COLOSTOMY
• It is done in advanced unresectable growth which presents with intestinal obstruction

19. Indications:
Chemotherapy regimens:
.
CHEMOTHERAPY
 Positive lymph nodes
 T2 stage
 Hematogenic spread, metastasis
 FOLFOX : 5-Fluorouracil, Folinic acid, Oxaliplatin
 FOLFIRI : 5-Fluorouracil, Folinic acid, Irinotecan
 CAPEOX : Capecitabine, Oxaliplatin

20. RADIOTHERAPY
 Only rectal adenocarcinoma in GIT responds well for RT
 Preoperative RT can be given to down stage the tumour so as to make it amenable for APR
or make it for anterior resection
 RT sterilises field; causes down staging of tumour; preserves sphincter
 For rectal cancer, usually combined chemoradiotherapy is given. It is given in the
neoadjuvant setting
 In small well differentiated growths Papillon’s intracavity curative radiotherapy can be tried
with proper follow-up
 Short course: 5-6 days chemoradiation → surgery
 Long course: 5-6 weeks chemoradiation → wait for 5-6 weeks → surgery

21. IMMUNOTHERAPY
 Used only in metastatic or recurrent colorectal cancers
 The agents used are:
 Bevacizumab: monoclonal antibody against VEGF
 Cetuximab: monoclonal antibody against EGFR
 Panitumumab: monoclonal antibody against EGFR
 Pembrolizumab, Nivolumab: PDL-1 inhibitors (used in microsatellite instability)

22. OTHER METHODS
o Electrocoagulation and decoring of the tumour, as a palliative
procedure; stenting.
o Laser photocoagulation, cryotherapy.
o Portal vein infusion; hepatic artery infusion for metastases.
o Tumour vaccines: Tumour antigen does not elicit immune response in
situ; but vaccines are injected to evoke immune response.
• BCG with irradiated tumour cells
• Monoclonal antibodies 17-1A (Murine lg G2A);
• CEA vaccines.

23. PROGNOSIS IN CARCINOMA RECTUM
5 YEAR SURVIVAL RATE PROGNOSTIC FACTORS FOLLOW-UP
STAGE I 90%
STAGE II 75%
STAGE III 40%
STAGE IV 5%
Size of the tumour
Differentiation
Mesorectal involvement
Stage of the disease
Nodal status, perineural spread
Distant spread
Circumferential resected margin
Adjuvant therapy used
Regular
Colonoscopy
CEA assessment
( carcinoembryonic antigen)
PET scan
MRI / CT scan
Colostomy care in APR

24. Thanks!