2. Incidence and Epidemiology
• In world- men-3rd (10.0% of all cancer cases)
women-2nd (9.4% of all cancer cases).
• 60% of cases -developed countries.
• The number of CRC-related deaths-accounting for 8% of all cancer deaths and making CRC the
fourth most common cause of death due to cancer.
• In India, the annual incidence rates (AARs) - colon and rectal cancer in men are 4.4 and 4.1 per
100000, respectively.
- women is 3.9 per 100000.
• Colon cancer ranks 8th and rectal cancer ranks 9th among men.
• women, rectal cancer does not figure in the top 10 cancers, whereas colon cancer ranks 9th.
• In the 2013 report, the highest AAR in india in men- Thiruvananthapuram (4.1) followed by Banglore
(3.9) and Mumbai (3.7) .
• The highest AAR in women for CRCs was recorded in Nagaland (5.2) followed by Aizwal (4.5)
3. Anatomy of rectum
• length-15 to 20 cm
• Extends from the rectosigmoid junction(fusion of the taenia coli into a completely
circumferential muscular layer) to the pelvic diaphragm-2-3 cm below and 4 cm in
front of the coccyx.
• Parts -Upper third-Intraperitoneal
-Middle third-retroperitoneal
-lower third- extraperitoneal
4. • Shape –
Variable in shape, the rectum follow the sacrococcygeal ligament
Widens below as ampulla, which is very distensible
• Three involutions or curves (valves of Houston)
-Proximal and distal valves- fold to the right
-Middle valve- folds to the left(Kohlrausch’s
valve)
• These valves are more properly called folds because they have no
specific function as impediments to flow.
• lost after full surgical mobilization of the rectum, a maneuver that may
provide approximately 5 cm of additional length to the rectum, greatly
facilitating the surgeon’s ability to fashion an anastomosis deep in the
pelvis.
6. • Peritoneal reflections at the middle third of
the rectum which is approx.
7-9 cm from the anal verge in
male
5-7.5 cm from the anal verge in
female
• Anteriorly form the pelvic cul-de-sac
(pouch of Douglas, rectouterine pouch)
serve as the site of drop metastatic
deposits(Blumer’s shelf) from visceral
tumors.
• Detected by a digital rectal examination.
• The rectum has two flexures-
• Sacral flexure(Dorsal bend) results from the
concave form of sacrum
• Perineal flexure(Ventral band)results from the
encirclement of the rectum by levator ani
muscle (puborectalis sling)
• Layers of the rectum-
7. Relations
• Anteriorly -Denonvilliers fascia(a fold of two layers of peritoneum)Separates the rectum
from
In males- Bladder, posterior prostate and seminal vesicles above and ductus
deference below
Female- the peritoneal fold form the pouch of Douglas-
back of cervix and vagina
• Posteriorly the rectum separated from the sacrum and coccyx by the
Mesorectum
Fascia propria
Presacral fascia
Waldeyer’s fascia
• laterally- the visceral fascia condenses to form the lateral ligament of the rectum
8.
9. Fascia
• Fascia propria- an extension of the endopelvic fascia, encloses the rectum and its
mesorectal fat, lymphatics, and vascular supply as a single unit;
-forms the lateral stalks of the rectum; and connects to the parietal
fascia on the pelvic sidewall.
• Presacral fascia is the parietal fascia that covers the sacrum and coccyx, presacral
plexus, pelvic autonomic nerves, and the middle sacral artery.
• Waldeyer’s fascia-Posterior thickening of presacral fascia, at the level of S4.
• Denonvilliers’ fascia -a fold of two layers of peritoneum separates the anterior rectal wall
from the prostate and seminal vesicles in the male and in female from the posterior wall of
vagina.
10. Lymphatic Drainage
• Upper and middle rectum- drains
into the inferior mesenteric nodes .
• lower rectum-drain into the
inferior mesenteric system(network
along the middle and inferior rectal
arteries, posteriorly along the
middle sacral artery, and anteriorly
through the channels to the retro-
vesical or rectovaginal septum) to
the iliac nodes, and ultimately, to
the periaortic nodes.
11. Nerve supply
• Pelvic autonomic nerves - paired
hypogastric (sympathetic), sacral
(parasympathetic), and Inferior
hypogastric nerves .
• Sympathetic nerves supply- originate
from L1 to L3, form the inferior mesenteric
plexus, travel through the superior
hypogastric plexus, and descend as the
hypogastric nerves to the pelvic plexus.
• Parasympathetic nerves, or nervi
erigentes, arise from S2 to S4 and join
the hypogastric nerves anterior and lateral
to the rectum to form the pelvic plexus
and ultimately the periprostatic plexus
• Fibers from this plexus innervate the
rectum as well as the bladder, ureter,
prostate, seminal vesicles, membranous
urethra, and corpora cavernosa.
• Injury to these autonomic nerves can lead
to impotence, bladder dysfunction, and
loss of normal defecatory mechanisms.
12. Risk factors for carcinoma Rectum
• History of a first-degree relative with colorectal cancer.
• Inflammatory bowel disease (IBD)
• Familial adenomatous polyposis (FAP)(autosomal dominant syndrome) defect in the APC
gene located on chromosome 5q21, Lynch syndrome, 5MYH genetic defect
• Dietary fats, especially red-meat fats, alcohol consumption
• Type, size, and number of polyps
• Sedentary lifestyle, high-fat diet
15. Adenoma-to carcinoma sequence
75% to 85% of adenomas-tubular, form a stalk
8% to 15% of adenomas -tubulovillous
5% to 10% of adenomas - villous. broad base, increased risk of cancer
16. Haggitt and colleagues classification
Polyps containing cancer according to the
depth of invasion
• Level 0: Carcinoma does not invade the
muscularis mucosae
(carcinoma in situ or intramucosal
carcinoma)
• Level 1: Carcinoma invades through the
muscularis mucosae into the submucosa
but is limited to the head of the polyp
• Level 2: Carcinoma invades the level of
the neck of the polyp
(junction between the head and
stalk)
• Level 3: Carcinoma invades any part of
the stalk
• Level 4: Carcinoma invades into the
submucosa of the bowel wall below the
17. Clinical Feature
• Hematochezia
• Tenesmus(sensation of incomplete defecation)
• Change in bowel habits or stool caliber
• Spurious diarrhoea(Early morning)
• Mucous discharge
• Sense of rectal “fullness”
• Feature of bowel obstruction
• Weight loss
• Nausea
• Vomiting
• Fatigue
• Anorexia
18. General Examination
Physical examination starts when the patient enters the clinic.
• Assessment of illness
• Mental state and intelligence
• Build
• State of nutrition
• Attitude
• Decubitus (position in bed)
• Colour of the skin, skin eruptions
• Pulse,blood pressure, respiration and temperature.
19. • Bimanual Examination- examination of the contents of the pelvis can be conveniently
examined during rectal examination by placing another hand on the abdomen.
This gives a better idea of the size, shape and nature of any pelvic mass.
Identification of bladder carcinoma
look at the examining finger for presence of faeces, blood, pus or mucus.
• Abdominal Examination- annular carcinoma at the upper part of the rectum an indistinct
lump may be felt at the left side of the abdomen.
Due to descending colon loaded with hard faeces(swelling pits on pressure)
Examine the liver for secondary metastasis.
Examine jaundice, hard subcutaneous nodules and free fluid.
• Lymph Nodes- hind gut will metastasize to the iliac groups of lymph nodes.
- lower part of the anal canal below the pectinate line commonly spreads
to
the inguinal group of lymph nodes and these are easily palpable.
20. Local Examination and Investigation
• Digital rectal examination (DRE)- any rectal growth.
-Assessment of tumor size.
-Mobility and fixation.
-Anterior or posterior location.
-Relationship to the sphincter mechanism.
-Identify Top of the anorectal ring.
-Distance from the anal verge.
• Rigid proctoscopy -Demonstrates the proximal and distal levels of the mass from anal
verge,
-Extent of circumferential involvement,
-Orientation within the lumen, and relationship to the vagina,
prostate, or
peritoneal reflection.
-Determining the feasibility of local excision
-To obtain an adequate tissue biopsy.
21. • Rigid sigmoidoscopy
• Flexible sigmoidoscopy – not used routinely
• flexibility of the instrument can give a false distance between the
tumor and the dentate line.
• Complete colonoscopy -to rule out synchronous cancers, which
occur 2% to 8% of the time.
• prefer colonoscopy over virtual colonoscopy so that we may not
only diagnose but also excise any amenable polyps.
• women should undergo a complete pelvic examination to determine
vaginal invasion.
22. • Abdominal and pelvic CT scans-
-Demonstrate regional tumor extension,lymphatic and distant
metastases, tumor related complications such as perforation or fistula
formation.
• CECT scan
-To assess the liver for metastatic disease,
-To evaluate the size and function of the kidneys.
-Assess the Ureteral involvement by the tumor and planning of ureteral
stent placement preoperatively.
-Invasion of contiguous structures such as the vagina, prostate, and
bladder lateral pelvic sidewall invasion.
24. Staging of rectal tumors on the basis of
endoscopic
Rectal Ultrasound
25. Indication of MRI
• For TNM staging
• Based on depth of tumor invasion as
well as presence of lymph node or
distant metastases
• To describe the anatomic extent of the
lesion.
• Aids in planning treatment
• Evaluating response to treatment
• Comparing the results of various
treatment regimens
• Determining prognosis.
29. Dukes’ Staging
A: limited to the rectal wall (15%). The prognosis is excellent (>90% 5-year
survival).
B: Extends to the extra rectal tissues, but without metastasis to the regional lymph
nodes (35%). The prognosis is reasonable (70% 5-year survival).
C: Secondary deposits in the regional lymph nodes (50%).
C1-local pararectal lymph nodes alone are involved
C2-Nodes accompanying the supplying blood vessels to their origin from the aorta stage
D-Presence of widespread metastases, usually hepatic
30. Astler- Coller modification of Duke’s
staging
• A- Tumor limited to the mucosa,
carcinoma in situ
• B1-Tumor grows through
submucosa but not through
muscularis propria
• B2-tumor grows beyond
muscularis propria
• C1-stage B1 with regional lymph
node metastases
• C2-stage B2 with regional lymph
node metastases
• D- Distant metastasis
31. Stage STAGE T N M Dukes MAC
0 Tis N0 M0 - -
1 T1 N0 M0 A A
T2 N0 M0 A B1
IIA T3 N0 M0 B B2
IIB T4a N0 M0 B B2
IIC T4b N0 M0 B B3
IIIA T1-T2 N1/N1c M0 C C1
T1 N2a M0 C C1
IIIB T3-T4a N1/N1c M0 C C2
T2-T3 N2a M0 C C1/C2
T1-T2 N2b M0 C C1
IIIC T4a N2a M0 C C2
T3-T4a N2b M0 C C2
T4b N1-N2 M0 C C3
IVA Any T Any N M1a - -
IVB Any T Any N M1b - -
32. Principles Of Treatment
• Depending on the stage of tumor
• location of the tumor within the rectum.
• Superficially invasive, small cancers -local excision.
• Deeply invasive tumors- require major surgery, such as low anterior
resection (LAR) or APR.
• Stage II and III rectal cancer, combined preoperative chemoradiotherapy.
• Stage IV- palliative therapy
33. Abdominoperineal resection
• Distal rectal cancers - abdominoperineal resection (APR)-first described by Miles, who noted high
failure rates after local excision.
• Involves the en bloc resection of the tumor as well as the surrounding lymph nodes and the anal
sphincters, resulting in a permanent end colostomy.
• Quite successful for early rectal cancers (stage I) in terms of survival,
• Significant morbidity of 61% and mortality ranging from 0% to 6.3%.
• Urinary complications - 50% and perineal wound infections 16%.
leaks from their stoma appliance sexual dysfunction
• The 5-year survival rates- 78% to 100% - stage I
45% to 73% - stage II
22% to 66% - stage III
34. • First phase of resection is abdominal approach.
• Patient lying in the supine position.
• Mobilisation of the distal sigmoid and rectum.
• Second phase of resection-perineal route.
• Dissect the anal canal cut the lesion and delivered by the perineal
route.
• Anal opening closed with the suture.
• Mature the colon with permanent end colostomy.
35. Perineal dissection: two-team synchronous approach. A. Projected lines of pelvic floor resection in the
vertical plane. B. Anal closure. C. Perineal incision. D. Incision line anterior to coccyx through anococcygeal
ligament through which scissors are used to gain entrance to the pelvis. E. Planes of pelvic dissection and
posterior plane of entry into pelvis through the pelvic floor. F. Projected lines of pelvic floor transection. G.
Lateral transection of levator ani muscle. H. Anterior transection of rectourethralis, puborectalis, and
pubococcygeus. I. Completion of anterior dissection and removal of rectum through perineal wound. J.
Pelvic floor closed with two drains in place.
36. Total Meso-rectal Excision
• Take out the tumor and mesorectal fat
also
• Done along with all type of resection
surgery
• Involves precise dissection and removal of
the entire rectal mesentery, including that
distal to the tumor, as an intact unit.
• Sharp dissection under direct vision in
the avascular, areolar plane between the
fascia propria of the rectum, which
encompasses the mesorectum, and the
parietal fascia overlying the pelvic wall
structures.
• Autonomic nerve preservation (ANP)
37. Low anterior resection
• Done in the mid and lower rectal
carcinoma.
• Resection done by dividing the
waldeyer’s fascia to enter into the
deep rectal space.
• Taken 2 cm safe margin from the
dentate line
Ultra-low anterior resection-
• Done only in distal rectal cancer.
• LAR with 0.5-1cm safe margin from
the dentate line.
Anterior resection
• Done in the proximal rectal cancer
• Safe margin 5 cm proximal and
distal to the tumor
• Stay above the waldeyer’s fascia
38. Local Excision
• Four approaches:-
-Transsphincteric
-Transanal
-Transcoccygeal
-TEM(Transanal endoscopic microsurgery)
• local recurrence rate of 7% to 33%
• Survival rates of 57% to 87%.
• Risk factors for local recurrence- positive surgical margins, transmural
extension, lymphovascular invasion, and
poorly differentiated/high grade histology.
39. Trans anal Excision
• Small distal rectal cancers
• lesion range from 6 to 8 cm above the anal verge,3 to 4 cm above the
anorectal ring.
40. Transcoccygeal Excision
• Originally popularized by Kraske
• Used for larger or more proximal lesions within the middle or distal third of
the rectum
• Approximately 4.8 cm from the dentate line.
• Useful for lesions on the posterior wall of the rectum but can be used for
anterior lesions.
• Bowel preparation and thrombosis precautions
• Placed in the prone jack knife position.
• Complication-fecal fistula(The incidence is 5% to 20%)
41. Transanal Endoscopic Microsurgery (TEM)
First described by Gerhard Buess of Tubingen, Germany, in 1980.
• Useful for small benign and malignant lesions in the mid and proximal
rectum that are too high for a traditional transanal excision.
• Anterior lesion-placed in the prone jack knife position.
• Posterior lesion- placed in a modified lithotomy position.
• lateral lesions, the patient can be placed on the appropriate side so that
the lesion is at the inferior quadrant of the visual field.
• The rectum is distended with carbon dioxide anywhere from 15- to 26-cm
water pressure so that the tumor can be visualized and the resection and
closure of the rectum can be completed.
43. • LAPAROSCOPIC SURGERY
Preservation of the autonomic nerves is also possible during laparoscopic
TME.
Early results confirmed complete resection of the mesorectum with intact
visceral fascia in all patients.
• ROBOTIC SURGERY
The main obstacles to robotic rectal cancer surgery (and even laparoscopic
when compared to open technique) - High learning curve
- Time constraints
- High cost of the procedure
-Operative time is longer
44. Pre operative bowel preparation
• Includes a clear-liquid diet 24 hours prior to surgery,
• laxatives and/or enemas,
• Oral antibiotics (erythromycin base and neomycin base)
• gastrointestinal tract irrigation with a solution of polyethylene glycol
electrolyte lavage (GoLYTELY or Miralax).
• Nichols/Condon preparation: neomycin 1 g and erythromycin base 1 g,
both non-absorbable antibiotics, by mouth at 5:00 pm and 10:00 pm on the
day prior to surgery.
• Perioperative systemic antibiotics should be given prior to incision time.
• Cover both aerobic and anaerobic intestinal bacteria is a second- or third
generation cephalosporin in combination with metronidazole.
45. Complications of surgical management
Early complications
• Infection
• Bleeding
• Wound problems
• Postoperative fever, tachycardia,
arrhythmias, tachypnea
• Urinary incontinence
Late complications
• Deep venous thrombosis
• Pulmonary embolism
• Myocardial infarction, Pneumonia, Renal
failure.
• Impaired sexual function
• Enterocutaneous fistula, or diffuse
peritonitis
• Anastomotic leaks between 4 and 7 days
• Stoma complications- ischemia,
retraction, hernia, stenosis, and prolapse.
46. Management Of Stage IV Disease-
• Palliative resection-depends on the degree of symptoms present.
-Bleeding, localized perforation, and obstruction
• Management options
1.Permanent diversion followed by chemotherapy (± radiotherapy
depending on local symptoms)
2. Palliative resection with a permanent colostomy followed by chemotherapy and
radiotherapy
3.Palliative resection with restoration of GI continuity followed by chemotherapy ±
radiation therapy.
Extend the median life expectancy of patients with stage IV disease from
approximately 8 months to nearly 2 years.
48. Neoadjuvent and Adjuvent chemotherapy
Tis; pT1N0, pT2N0 Observation
pT3–4N0, pT1–3N1–2,
pT4N1–2
5-FU±LV or FOLFOX or capecitabine ± oxaliplatin followed by
infusional
5-FU/radiotherapy (RT)or capecitabine + RT followed by 5-
FU±LV
OR FOLFOX or capecitabine ±oxaliplatin or infusional5-FU/RT
OR
capecitabine + RT followed by 5-FU±LV or FOLFOX or
capecitabine ±
oxaliplatin
cT3N0, any TN1–2 Preoperative infusional 5-FU/RT or capecitabine + RT
followed by surgery
and then 5-FU±LV or FOLFOX or capecitabine ± oxaliplatin
cT4 and/or locally unresectable Infusional 5-FU/RT or capecitabine + RT followed by surgical
resection
if possible and then 5-FU±LV or FOLFOX or capecitabine ±
49. Regimen of chemotherapeutic drugs
1-FOLFOX (2-weekly regimen)
Day 1 Oxaliplatin 85mg/m2 ,infusion over 2h
Folinic acid 350mg, infusion over 2 h
5-FU 400mg/m2 , bolus
5-FU 1200mg/m2 , continuous infusion over 24 h
Day 2 5-FU 1200mg/m2 ,continuous infusion over 24 h
2-CAPOX (3-weekly regimen)
Day 1 Oxaliplatin 130mg/m2 , intravenous infusion over 2h
Days 1–14 Capecitabine 1700 mg/m2 , oral in 2 divided doses Age >75 years: reduced starting
dose; oxaliplatin 100mg/m2 andcapecitabine 1300mg·m-2day-1 for 14 days followed by a 7-day rest
period Capecitabine (3-weekly regimen)
Capecitabine: 2000mg/m-2day-1 in 2 divided doses for 14 days followed by a 1-week break.
50. 3-FOLFIRI (2-weekly regimen)
Day 1 Irinotecan 180mg/m2 ,intravenous infusion over 1 h
Folinic acid 350mg,intravenous infusion over 2 h
5-FU 400mg/m2 ,intravenous bolus 5-FU 1200mg/m2 ,
continuous
intravenous infusion over 24 h Day 2 5-FU 1200mg/m2 ,
continuous
intravenous infusion over 24 h
4-CAPIRI (3-weekly regimen)
Day 1 Irinotecan 200mg/m2 ,intravenous infusion over 60
min
Days 1–14 Capecitabine 1700mg,oral in 2 divided doses
followed by a 1-week break.
51. Management of obstructing, metastatic, and
recurrent
rectal cancer
• Obstructing Cancer- a loop ileostomy is constructed for diversion.
• Metastatic Rectal Cancer- Presented with incurable metastatic disease and
life expectancy is greater than 6 months
Palliative rectal resection.
Neoadjuvant chemoradiation-staged T3 or N1
Rectal stents or laser destruction of the tumor- to
maintain an adequate lumen.
52. • Recurrent Rectal Cancer-
Developed at the distal margin of the anastomosis
Mostly develop from residual cancer on the pelvic sidewall
or
inadequate TME with mesorectal nodes that are not
excised as
part of the endopelvic envelope
• Performed in an operating room–radiation therapy suite.(Intra
Operative Radiation Therapy)
• Resection with negative microscopic margins and absence of
vascular invasion - predicts improved local control and survival after
resection and IORT.
• Morbidities of IORT -peripheral neuropathy and ureteral stenosis.
53. Surveillance
• After curative resection, long-term follow-up includes routine screening for rectal recurrence and
metachronous colorectal neoplasms.
• 60% to 84% of recurrences-in the first 24 months
90% within 48 months.
• Median time to recurrence -11 to 22 months.
• Local recurrence rates- between 4% and 50%.
• Median survival after recurrences-40 months.
• Survival rate in different stages
54. Follow-up
• Patients are seen postoperatively at 2 weeks and then every 3 months for
2 years.
• At each visit, the patient undergoes DRE and sigmoidoscopy, and a CEA
level is obtained.
• As per the National Comprehensive Cancer Network (NCCN) guidelines,
we recommend at 1 year post-resection a colonoscopy and CT scans of
the chest, abdomen, and pelvis.
• A CT scan is performed annually until 3 to 5 years postoperatively.
• Colonoscopy frequency is determined by the findings at 1 year.
• If there are no polyps and no recurrence, the follow-up interval
colonoscopy can be lengthened to 3 years, and then if normal even up to a
5-year interval after that.
55. • Certainly, in patients who have polyps, Lynch syndrome, or are
younger at the initial age of diagnosis, a shorter interval such as
every 3 years is recommended.
• After the initial 2 years of surveillance, patients continue to be
followed every 6 months with CEA levels and physical examinations
until 5 years after the surgery.
• At 5 years, if the patient has had no recurrence, he or she may be
followed yearly with clinic visits and may undergo colonoscopy
every 3 to 5 years as outlined above.
• Of course, closer observation is indicated for patients at high risk
for subsequent cancer formation, such as patients with IBD,
polyposis syndromes, or a strong family history of colorectal cancer.
