Diseases of the rectum and anal canal in Thai
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Rectal procidentia, or rectal prolapse, is the full-thickness circumferential intussusception of the rectum through the anal verge. It can be incomplete involving just the mucosa, or complete involving the full rectal wall. Complete prolapse is classified as first degree if the prolapse remains outside the anus, second degree if it reduces spontaneously on lying down, or third degree if it requires manual reduction. Predisposing factors include constipation, pelvic floor weakness, rectocele, and increased intra-abdominal pressure. Treatment options include pelvic floor repair, rectopexy to elevate the rectum, and resection of redundant sigmoid colon.
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Diseases of the rectum and anal canal in Thai
- 1. 8 Diseases of the rectum /01234056789:;<=81-3 %&'()*+),- rectum 4,-567%&'&89:;<=(8->:,=-*?7@7A sigmoid colon :IAA7J9KL74M7&()NA5879987%&'()*>)K=?(':;<= S3 P(8MI5JPQ;JN>R,=-987%&'()*>)K=?(':;<= sacral promontory %V&KW:&XYZ)K>9[;<=87:A5'7?>:,W- levator ani ^_=*@`9AA5IZ%VY'7:+5I*A57J>Va: anal canal (8-%V %&'()*J79V)`?7[ 12-15 >^:(K>?() :I*d-*%&'()*V)`A-ZY'9JRIW: mucosa, submucosa, A5'7?>:,W- circular, A5'7?>:,W- longitudinal P5`RIW: serosa ^_=*QZ>gQ7`%&'()*&89:;<=-Jh8i: intraperitoneum %&'()*PJA@7A567%&'i+j8 (colon) mYJ 1. %&'()*%?8?< taenia >+?,-:567%&'i+j8 >:,=-*@7A taenia d-*567%&'i+j8%Y')9?AI:>Va:A5'7?>:,W- longitudinal ;<=RIW::-A&XY (outer layer) d-*%&'()* 2. %&'()*%?8?< mesentery, sacculations P5`%?8?< appendicae epiploicae %&'()*?< 3 lateral curves 4,- &89:Z:P5`587* convex %VY'7:d97 &89:A57* convex %VY'7:^'7J >J,=-ZXRIW: mucosa d-*%&'()*Z7*Z)K>9[+:7(I9d_W: >)<JA987 valves of Houston ^_=*mYJ&89:i+j8?< V)`?7[ 3 -I:?IAiR'PZ8*%&'()* --A>Va: 3 &89: 4,-&89:Z: (upper rectum) &89:A57* (middle rectum) P5`&89:587* (lower rectum) ()hV;<= 1) =BCDEF 1 /01234056789:;<=82
- 2. 9 %&'()*97*(I9Y'7:+:'7(8-A)`YhA sacrum P5`A)`YhA coccyx )9?;IW*A5'7?>:,W- levator ani, A5'7?>:,W- coccygeal, +5-Y>5,-YPY* medial sacral P5`A5X8?V)`&7; sacral i:>QMR7J;7*Y'7:+:'7d-*%&'()*>Va:A)`>Q7`Vq&&79` ;8-Vq&&79` ;8-:67-&X@K (vas deferens), (8-?:W67>R,W- (seminal vesicles) P5`(8-?5hA+?7A &89:i:>QM+jK*>Va:?Y5hA ;8-:67%d8 )I*%d8 V7A?Y5hA P5`&89:Z:d-*:I*Y'7:+5I*d-*R8-*45-Y %&'()*?<>J,=-ZXR8-*;'-* (parietal peritoneum) VA45X? mYJ&89:Z:d-*%&'()*?<>J,=-ZXR8-*;'-*VA 45X?;7*Y'7:+:'7P5`Y'7:d'7* &89:;7*Y'7:+5I*>J,=-ZXR8-*;'-*;<=45X?567%&'i+j8&89: sigmoid 9AA5IZ%V 45X?:I*R8-*;'-*;7*Y'7:+5I*i:(67P+:8*>+:,-(8-%&'()* @_*>)<JAZ)K>9[:<W987 posterior peritoneal reflection %&'()*&89:A57*?<>J,=-ZXR8-*;'-*45X?>gQ7`;7*Y'7:+:'7>;87:IW: @_*?< lateral peritoneal reflections ;<=Y'7:d'7*;IW* 2 d'7*d-*Z)K>9[)-J(8-)`+987*%&'()*&89:Z:P5`&89:587*d-*%&'()* )9?;IW*?< anterior peritoneal reflection ;7*Y'7:+:'7Z)K>9[)-J(8-)`+987*%&'()*&89:A57*P5`&89:587* >:,=-*@7A &89:587*d-*%&'()*%?8?<>J,=-ZXR8-*;'-*VA45X?@_*>)<JA987 extraperitoneal part DenonvillierHs fascia >)K=?@7AZ)K>9[ anterior peritoneal reflection %V&KW:&XY;<= urogenital diaphragm PJA%&'()*--A@7A(8-?:W67>R,W- (8-?5hA+?7A +),-R8-*45-Y WaldeyerHs fascia +),- retrorectal fascia >R,=-?(8-)`+987* S4 AIZY'7:+5I*d-*%&'()* =LMMNO7PQOR7PSP8: Z)K>9[&89:Z:P5`&89:A57*d-*%&'()*>5<WJ*mYJ+5-Y>5,-YPY* superior rectal +),->)<JA-<AR,=-+:_=*987+5-Y>5,-YPY* superior hemorrhoidectomy ^_=*>Va:+5-Y>5,-Y &89:V57J&XYd-*+5-Y>5,-YPY* inferior mesenteric &89:587*d-*%&'()*>5<WJ*mYJ+5-Y>5,-YPY* inferior rectal ^_=*>Va:Pd:*d-*+5-Y>5,-YPY* internal pudendal i:h'Vv9J)'-J5` 22.22 QZ+5-Y>5,-YPY* middle rectal ;7*Y'7:d'7*d-*%&'()*&89:A57* ^_=* -7@>Va:Pd:*d-*+5-Y>5,-YPY* internal pudendal +),- inferior gluteal +),- internal iliac >5<WJ*%&'()* &89:A57* -J87*%)Aw(7?+5-Y>5,-YPY*;<=>5<WJ*%&'()*;IW*+?Y?<A7)(8->R,=-?AI: ()hV;<= 2)
- 3. 10 =BCDEF 2 S:P8NO7PQOR7PSP8DEFQOEU189:;<=82 (?-*@7A;7*Y'7:+5I*) =LMMNO7PQOR7PPV0: Z)K>9[%&'()*&89:Z:P5`&89:A57*>5,-YY67>;>d'7&h8+5-Y>5,-YY67 superior rectal ^_=*>;>d'7+5-Y>5,-YY67 inferior mesenteric >d'7&h8)`ZZ+5-Y>5,-YY67 portal &89:587*d-*%&'()*>5,-YY67>;>d'7&h8+5-Y>5,-YY67 middle rectal, +5-Y>5,-YY67 internal iliac P5`)`ZZ+5-Y>5,-YY67 caval (7?567YIZ =LMMNO7PWUV0QNOR78: Z)K>9[&89:Z:P5`&89:A57*d-*%&'()* :W67>+5,-*>;>d'7&h8(8-?:W67>+5,-* inferior mesenteric Z)K>9[&89:587*d-*%&'()*:W67>+5,-*%V(7?+5-Y>5,-YPY* superior rectal >;>d'7&h8(8-?:W67>+5,-* inferior mesenteric :-A@7A:<W&7?7)x%V;7*Y'7:d'7*(7?+5-Y>5,-YPY* middle P5` inferior rectal >Q,=->;>d'7&h8(8-?:W67>+5,-* internal iliac (7?567YIZ =LMMC=L:0D: sympathetic innervation ?7@7A S1-3 4,->&':V)`&7; presacral +),- superior hypogastric plexus ?7@7A hypogastric plexus P5`>&':V)`&7; lateral lumbar splanchnic parasympathetic innervation ?7@7A S2-4 )9?>Va: nervi erigentes Z)K>9[Y'7:d'7*d-*%&'()* &89:587* mYJ sympathetic P5` parasympathetic ?<A7)>R,=-?(8-AI:Z)K>9[Y'7:+:'7P5`Y'7:+5I*d-*%&' ()*&89:587*>Va: pelvic plexus ^_=*?<5(8-A7)Z<ZP5`457J(I9d-*%&'()* )9?;IW*49Z4X? erection P5` ejaculation i:>QMR7J :=E=23D106789:;<=83-5 >?,=--X@@7)`>45,=-:(I9@7A567%&'i+j8&89: sigmoid 5*?7&h8%&'()* ;67i+':I*d-*%&'()*xhAJ,Y(I9 --A>AKY reflex A)`(X':i+'?<A7)457J(I9d-*A5'7?>:,W-+h)hY;97)+:IA (anal sphincter) P5`A5'7?>:,W-d-* -X'*>RK*A)7: (pelvic floor) i+'>AKYA7)dIZx87J-X@@7)`
- 4. 11 tenesmus 4,--7A7);<=h'Vv9J)h'&_A+5I*A7)x87J-X@@7)`987>+?,-:?<A7)x87J-X@@7)`%?8&XY mYJ-7@ ?<&7>+(X@7AA7);67*7:d-*%&'()*P5`;97)+:IAKYVA(K ;67i+'%?8&7?7)xdIZx87J-X@@7)`@:+?Y%Y' +),- >AKY@7A&7>+(X-,=: >R8:?<A'-:>:,W-+),-P5i:%&'()* 4-JA)`(X':;67i+'>d'7i@KY987JI*?<-X@@7)`4'7*i: %&'()* X=5DEFYMMZ716789:;<=8 Rectal procidentia6-8 W310] -7@>)<JA-<AR,=-+:_=*987 rectal prolapse 4,-A7)J,=:d-*:I*%&'()*87:A5'7?>:,W-+h)hY;97)+:IA mYJ>R,=-987>AKY@7A circumferential intussuception d-*%&'()*^_=*>)K=?(':;<=Z)K>9[ 3 :KW9>+:,-@7A anal verge PZ8* rectal procidentia (7?)`YIZ497?)X:P)*%Y'YI*(8-%V:<W ()hV;<= 3) 1. incomplete +),- mucosal prolapse ?<A7)J,=:>gQ7`RIW:>J,=-ZXL7Ji:d-*%&'()* 2. complete +),- full-thickness wall prolapse ?<A7)J,=:4)Z;XARIW:d-*%&'()* PZ8*>Va: - first degree +?7Jx_*A7)J,=:d-*:I*%&'()*>gQ7`L7Ji:R8-*;97)+:IA ()9@%?8QZ 497?KYVA(K@7AL7J:-A;97)+:IA - second degree QZ:I*d-*%&'()*J,=:--A?7:-AV7A;97)+:IA>gQ7`>957>Z8* - third degree QZ:I*%&'()*J,=:--A?7:-AV7A;97)+:IA(5-Y>957 =BCDEF 3 S:P8 rectal procidentia bW=L1L<Z08c6
- 5. 12 Ceffg1:Z8Q:=3] (predisposing factors) ?IAQZ rectal procidentia )89?AIZh'Vv9J;<=?<A7)>Z8*x87J-X@@7)`-Jh8>&?-| >R8:L79`;'-*hA>),W-)I* +),-;'-*>&<J>),W-)I* +),-i:A)[<;<=?<5IA}[`;7*A7J9KL74 +),-A7);67*7:d-*)`ZZA5'7?>:,W-Z)K>9[-X'*>RK* A)7:+),->&':V)`&7;;<=49Z4X?A7);67*7:d-*)`ZZA7)dIZx87J-X@@7)`+),-A5'7?>:,W-Z)K>9[-X'*>RK*A)7: >&<J%V >R8:i:h'+jK*;<=45-YZX();7*R8-*45-Y +),-h'Vv9J%Y')IZA7)87(IYZ)K>9[-X'*>RK*A)7:P5`;97) +:IA?7A8-: +),-A7)%Y')IZ-XZI(K>+(X(8-Z)K>9[YI*A5879@7A&7>+(X-,=: Y10k323D10/0123405 -7@?<497?KYVA(K+57J-J87*V)`A-ZAI:;67i+'?<m-A7&>AKY rectal procedentia %Y'*87Jd_W: %Y'PA8 ()hV;<= 4) 1. A5'7?>:,W-d-* pelvic floor P5` endopelvic fascia +J8-: 2. Z)K>9[ cul-de-sac of Douglas 5_AKYVA(K 3. 567%&'&89: rectosigmoid J79>AK:%V (redundant) 4. A5'7?>:,W-+h)hY;97)+:IA+J8-: 5. %&'()*-Jh8i:P:9YK=* >:,=-*@7A>A7`AIZA)`YhA sacrum P5`-X'*>RK*A)7:+59?| =BCDEF 4 S:P8Y10k323D10/0123405678 rectal procidentia6 70/0=D085O3W3/ QZi:h'+jK*?7AA987h'R7J 6 >;87 ?IAQZ>?,=-?<-7JX 50 V€d_W:%V h'Vv9J?IAQZPQ;JNY'9J497?>d'7i@ KY987(:>-*Vv9J>Va:m)4)KY&<Y9*;97)+:IA >:,=-*@7A?<A'-::K=?&<R?QhPY*J,=:;7*;97)+:IA>957x87J
- 6. 13 -X@@7)` +7A>Va:?7A-7@%?8&7?7)xYI:A'-:A5IZ>d'7%Vi:;97)+:IA%Y' -7@?<-7A7)A5IW:Vq&&79`KYVA(K +),-?<A7)J,=:d-*?Y5hA--A;7*R8-*45-Y)89?Y'9J ()9@)87*A7JQZA'-:&<PY*J,=:--A?7;7*;97)+:IA ?< concentric fold -7@Z9?PY*RW67+),->AKY P5AY;IZ+7A567%&'J,=:--A:-AV7A;97)+:IA>Va:>957:7:P5`mYJ;<=%?8&7?7)xYI:A5IZ>d'7%V%Y' i:A)[< ;<=V)`9I(K&*&IJ P(8()9@)87*A7J%?8QZ P:`:67i+'h'Vv9J:I=*x87J-X@@7)J-*| P5`>Z8*x87J-X@@7)` @`QZ A'-:J,=:--A?7%Y' 49)()9@Yh497?Pdw*P)*d-*A5'7?>:,W-+h)hY;97)+:IAY'9J /0=23W3fmg1S1/X=5 PJA@7A prolapse internal hemorrhoid mYJA7)Yh fold >Va:&674Ij mYJ rectal procedentia @` QZ concentric fold i:d[`;<= prolapse internal hemorrhoid QZ>Va: radial fold /0=:RM5;WD08N;78Cn3Mg<3/0= - 49);67A7)>-A^>)JN&9:PV•*;7*;97)+:IA (barium enema) +),-&8-*A5'-*567%&'i+j8 (colonoscopy +),- sigmoidoscopy) >Q,=-+7&7>+(X;<=>Va: leading point d-*A7)A5,:AI:d-*567%&'+),- m)4-,=:;<=-7@QZ)89?>R8: >:,W-*-A 567%&'-IA>&Z +),- diverticular disease - P:`:67i+'()9@ defecography A)[<;<=-7A7)d-*h'Vv9J>d'7%Y'AIZm)4 rectal procidentia P(8()9@)87*A7J%?8QZ497?KYVA(KYI*A5879 >:,=-*@7A>Va:%?8?7A (first degree) ;67i+'%?8&7?7)x?-*>+w: QJ7‚K&L7Q@7AA7)()9@)87*A7J P(8>?,=-()9@Y'9JA7);67 defecography ^_=*+?7Jx_*A7)&9:&7);_Z)I*&< >d'7;7*;97)+:IA@7A:IW:ZI:;_AL7Q>-A^>)JNi:d[`i+'h'Vv9J>Z8*x87J-X@@7)` ;67i+'&7?7)x?-*>+w:567%&' ;<=>45,=-:;<=>d'7A5,:AK:AI:L7Ji:%&'()*%Y' - A7);67 anorectal manometry ^_=*+?7Jx_*A7)()9@A7);67*7:d-*%&'()*P5`;97)+:IAi:A7) dIZx87J-X@@7)` R89Ji:A7)V)`>?K:497?Pdw*P)*d-*A5'7?>:,W-+h)hY;97)+:IAA8-:P5`+5I*A7)87(IY%Y' -J87*%)Aw(7?-7@%?8@67>Va:('-*;67i:h'Vv9J;XA)7J >:,=-*@7A%?8>V5<=J:P:A7))IA}7 /0==g/o09 ?<A7)87(IY)IA}7+57J9K‚< P(8%?8?<9K‚<iY;<=>Va:?7()„7:P5`Y<;<=&XY YI*:IW:A7)>5,-A9K‚<A7)87(IY ('-*QK@7)[7x_*497?)X:P)*d-*m)4 &L7Q)87*A7J497?Pdw*P)*d-*h'Vv9J -7JX 497?Pdw*P)*d-* A5'7?>:,W-+h)hY;97)+:IA A7)?<>QM&I?QI:‚N P5`L79`P;)A^'-:+5I*87(IY>Va:&674Ij A7)>()<J?h'Vv9J>Q,=->d'7)IZA7)87(IY)IA}7 @67>Va:('-*;67A7)()9@P5`V)`>?K:h'Vv9JA8-:A7)87(IY %Y'PA8 A7)>@7`>5,-Y>Q,=-()9@ complete blood count )`YIZ:W67(75P5`>A5,-P)8 A7);67*7:d-*%( (IZ >-A^>)JNV-Y A7)()9@45,=:%……•7+I9i@ >:,=-*@7Ah'Vv9Jm)4:<W?IA>Va:h'&h*-7JX^_=*?<Vq@@IJ>&<=J*&h*(8-A7)>d'7)IZA7)87(IY )9?x_*A7)V)`>?K:m)4 V)`@67(I9d-*h'Vv9J
- 7. 14 +7A97*P:987@`87(IY>Q,=-(IY(8-567%&'-7@@67>Va:('-*>()<J?567%&'i+'&`-7YA8-:A7)87(IY (bowel preparation) ^_=*V)`A-ZY'9J mechanical bowel preparation mYJ?<@XYV)`&*4N>Q,=-%?8i+'?< -X@@7)`+5*>+5,-i:567%&'i+j8>:,=-*@7A-7@;67i+'>AKYA7)V:>V†‡-:)`+987*A7)87(IY :-A@7A:<W-7@ )89?AIZA7);67 chemical bowel preparation mYJA7)i+'J7VˆKR<9:`)IZV)`;7:A8-:A7)87(IY>Q,=-5Y V)K?7[PZ4;<>)<Ji:567%&' >:,=-*@7AMI5JPQ;JNZ7*A5X8?>R,=-987>Va:&7>+(Xd-*A7)(KY>R,W-i:R8-*;'-*P5`;<= P587(IY ;IW*:<W('-*i+')89?AIZJ7VˆKR<9:`R:KYg<Y>d'7>&':>5,-YA8-:A7)87(IY &7?7)xPZ8*A7)87(IY)IA}7--A>Va: 2 9K‚<i+j8| 4,- 1.A7)87(IY)IA}787:;7*:I*+:'7;'-* (abdominal approach) 4,-A7)87(IY>V‰Y:I*+:'7;'-* >Q,=-J_Y%&'()*>d'7AIZA)`YhA sacrum (rectoplexy) Y'9J9K‚<(87*| >R8:A7)>JwZ%&'()*J_YAIZA)`YhA sacrum Y'9J%+?%?85`57J +),-iR'9I&YX&I*>4)7`+N (mesh) +X'?)-Z%&'()*P5`>JwZJ_Y>d'7AIZA)`YhA sacrum mYJ-7@ )89?AIZA7)(IY567%&';<=J,YJ79--A (anterior resection) -:_=*i:Vq@@XZI:-7@87(IYY'9JA5'-* (laparoscopic surgery) >Q,=-5Yd:7Yd-*P587(IYP5`-7A7)V9YP5+5I*A7)87(IY -<A;IW*;67i+'h'Vv9J…†‡:(I9+5I*87(IY %Y'>)w9JK=*d_W: d'-Y<d-*A7)87(IYY'9J9K‚<:<W4,- QZ-I()7A7)A5IZ>Va:^W67 (recurrent rate) (=67 -J87*%)Aw(7?>Va: A7)87(IYi+j8;<=('-*A7)A7)Y?J7&5Z ?<P587(IYi+j8;67i+'h'Vv9J%?8&7?7)xR89J>+5,-(:>-*%Y'i: )`J`P)A+5I*87(IY ^_=*-7@:67?7^_=*L79`P;)A^'-:L7J+5I*A7)87(IY-,=:| )9?;IW*A7)87(IYR:KY:<W&8*5 A)`;Z(8->&':V)`&7;;<=49Z4X?-X'*>RK*A)7:P5`A7)?<>QM&I?QI:‚XN +7AiR'9I&YX&I*>4)7`+N-7@;67i+'>AKY 567%&'-XY(I:>:,=-*@7A)IYP:8:>AK:%V%Y' 2. A7)87(IY)IA}787:;7*;97)+:IA ^_=*?< 2 9K‚<;<=:KJ?iR'i:Vq@@XZI: ?<9I(xXV)`&*4N5Y567%&'&89:;<= J,YJ79 -7@;67mYJA7)87(IY567%&'&89::IW:--A (Altemeier procedure +),- proctosigmoidectomy) +),- A7)>JwZ567%&'i+'QIZ^'-:AI: (Delorme operation) A7)87(IY87:;7*;97)+:IA&7?7)x87(IY%Y'mYJA7) g<YJ7R7>gQ7`;<=Z)K>9[)-Z)h;97)+:IA+),-;7*%d&I:+5I* )9?;IW*)-JP587(IY-Jh8L7Ji:R8-*;97)+:IA ;67i+'h'Vv9J%?8?<497?>@wZV9YL7J+5I*A7)87(IY &7?7)xR89J>+5,-(:>-*%Y' >Va:A7)87(IY;<=%?8)ZA9: A7);67*7:d-*>&':V)`&7;;<=49Z4X?-X'*>RK*A)7: @_*%?8?<5A)`;Z(8-A7)?<>QM&I?QI:‚XNi:>957(8-?7 P5` &7?7)x>JwZ^8-?>Q,=-PA'%dL79` incontinence %Y'-<AY'9J -J87*%)Aw(7?A7)87(IYR:KY:<WQZ-I()7A7)>Va: ^W67&h*A987A7)87(IY87:;7*:I*+:'7;'-* i:-Y<(?<A7)87(IYmYJiR'59Y +),-9I&YX-J87*-,=:)IY)-ZA5'7?>:,W-+h)hY;97)+:IA>Q,=-%?8i+'567%&'J,=: --A?7:-A;97)+:IA (Thiersch operation) P(8%?8?<;<=iR'i:Vq@@XZI: >:,=-*@7A>Va:A7)PA'Vqj+7;<=KY9K‚< P5`;67i+'-X@@7)`567Z7A('-*&9:-X@@7)`@_*@`&7?7)xx87J-X@@7)`%Y'
- 8. 15 A7)YhP5i:)`J`+5I*A7)87(IY +7A?<A7)(IY(8-567%&'@67>Va:('-*i+'h'Vv9J*YA7))IZV)`;7::W67P5`-7+7)@:A987567%&'@`;67*7: +),-?I=:i@987)-J(8-567%&'(KYY< P5`@67>Va:('-*i+'J7VˆKR<9:`-J87*:'-JL7Ji:)`J` 24 RI=9m?*P)A:IZ@7A 4)IW*P)A;<=i+'A8-:A7)87(IY Rectal carcinoma10-12 ?`>)w*%&'()*?IA>Va:R:KY adenocarcinoma >+?,-:?`>)w*567%&'i+j8 A7)A)`@7Jd-*m)4?< 5IA}[`45'7JAI: -J87*%)Aw(7?>:,=-*@7A%&'()*>Va:-9IJ9`;<=-Jh8i:-X'*>RK*A)7: @_*?<-7A7)P5`-7A7)P&Y* d-*m)4 )9?;IW*d'-QK@7)[7i:A7))IA}7(87*%V@7A?`>)w*567%&'i+j8 70/0=D085O3W3/ -7@()9@QZ@7AA7)()9@4IYA)-*m)4mYJh'Vv9J%?8?<-7A7) +),-QZPQ;JN>:,=-*@7A?<>5,-Y--A ;7*;97)+:IA mYJ-7@>Va:>5,-Y&<PY*&Y+),->5,-Y&<45W67 >5,-Y-7@V:AIZ-X@@7)`>+59+),-PJA@7A -X@@7)`Pdw* P(8--AA8-:+),---AQ)'-?AI:+),---A(7?+5I*A7)x87J-X@@7)` -7@?<?hAV: x87J-X@@7)` 567Z7A h'Vv9J?IA('-*)IZV)`;7:J7)`Z7J+),-iR'J7&9:;7*;97)+:IA>Q,=-i+'-X@@7)`*87Jd_W: -X@@7)`A'-: >5wA5*>+?,-:d<WPQ` ?<497?)h'&_A>+?,-:x87J-X@@7)`%?8+?Y +),-?<;'-*hA&5IZ;'-*>&<J h'Vv9J?IA>d'7i@KY 987>Va:m)4)KY&<Y9*;97) :-A@7A:<W-7@?<-7A7))89?-,=:| >R8: >Z,=--7+7) 45,=:%&' -7>@<J: :W67+:IA(I95Y5* V9Y;'-* Vq&&79`567Z7A ?<>5,-Y--A)89?Y'9J +),-?<>5,-Y--AKYVA(K;7*R8-*45-Y )9?;IW*-7@QZ-7A7) V9Y5_A|i:-X'*>RK*A)7:P5`)'795*%V;<=d7 A)[<;<=A'-:?`>)w*5XA57?%Vi:-9IJ9`d'7*>4<J* A7)()9@)87*A7J;7*;97)+:IA-7@4567%Y'A'-:d)Xd)`;<=>J,=-ZXL7Ji:d-*%&'()* +7AA'-:?`>)w*-Jh8 Z)K>9[&89:587*+),-&89:A57*d-*%&'()* +),-?<?hA>5,-Y+),-&<-X@@7)`;<=KYVA(K(KYV57J:KW9 49)V)`>?K: 497?Pdw*P)*d-*A5'7?>:,W-+h)hY;97)+:IA >:,=-*@7A>Va:d'-QK@7)[7i:A7)>5,-A9K‚<87(IY)IA}7 ()9@&L7Q)87*A7JmYJ;I=9%V Yh497?Pdw*P)*d-*h'Vv9J -7A7)^<Y >+5,-* A7);67*7:d-*)`ZZ +7Ji@ +I9i@P5`+5-Y>5,-Y A7)()9@R8-*;'-*>Q,=-V)`>?K:987?<-X@@7)`4'7*i:567%&'?7A+),-%?8 ?<(IZm( 4567%Y'A'-:L7Ji:R8-*;'-*+),-%?8 Z7*)7J+7A?<A7)A)`@7J%V;<=>J,=-ZXL7Ji:R8-*;'-* (carcinomatosis peritonei) -7@()9@QZ?<:W67i:R8-*;'-* (ascites) )9?x_*A7)4567(8-?:W67>+5,-*Z)K>9[>+:,-%+V57)'7P5` d7+:<Z;IW* 2 d'7* /0=<=2fD08N;78Cn3Mg<3/0= - endoscopy &7?7)xZ-A5IA}[` d:7Y (67P+:8*d-*>:,W-*-A V)`>?K:%Y'987A'-:?`>)w*m(-XY lumen d-*567%&'+),-%?8 P5`&7?7)x+JKZRKW:>:,W-&8*()9@;7*QJ7‚K9K;J7 A)[<;<=>:,W-*-A>Va:%?8?7AP:`:67 i+';67 colonoscopy +),-;67 barium enema >Q,=-V)`>?K:567%&'i+j8&89:;<=-Jh8>+:,-(8->:,W-*-A:<W >:,=-*@7A -7@QZ>:,W-*-A;<=-,=: (synchronous lesion) +),-(K=*>:,W- (polyp) )89?Y'9J
- 9. 16 - endorectal ultrasonography >Q,=-V)`>?K:497?5_Ad-*A'-:?`>)w*;<=5XA57?;<=:I*%&'()* &7?7)xZ-A%Y'987A'-:?`>)w*AY>Z<JY+),-5XA57?&h8-9IJ9`-,=:;<=-Jh8d'7*>4<J*+),-%?8 )9?;IW*&7?7)x()9@QZ (8-?:W67>+5,-*Z)K>9[d'7*>4<J*^_=*m(d_W:>:,=-*@7A?<>^55N?`>)w*5XA57?%V - A7)()9@>Q,=-V)`>?K:A7)5XA57?P5`A7)A)`@7Jd-*(I9m)4%V&h8-9IJ9`-,=:| >R8: V-Y (IZ -9IJ9`i:-X'*>RK*A)7: %Y'PA8A7);67 abdominal ultrasonography P5`>-A^>)JNV-Y +),-A7);67 CT scan ;<=R8-*-AP5`;'-* :-A@7A:<WA7);67 magnetic resonance imaging (MRI) Z)K>9[-X'*>RK*A)7:&7?7)x V)`>?K:A7)5XA57?d-*A'-:?`>)w*P5`(8-?:W67>+5,-*Z)K>9[d'7*>4<J*%Y' - A7)()9@+7487 carcinoembryonic antigen (CEA) i:>5,-Y^_=*-7@&h*d_W:i:h'Vv9Jm)4?`>)w*%&' ()*Z7*)7J mYJ>gQ7`A)[<;<=?<>^55N?`>)w*A)`@7J%V;<=(IZ P5`&7?7)xiR'(KY(7?A7))IA}7mYJ+7AQZ987 487 CEA &h*d_W:i+'&*&IJ987-7@?<A7)A5IZ>Va:^W67d-*m)4 ^_=*mYJVA(K%?849)&h*A987 5 ng/mL - A7)()9@;7*+'-*VˆKZI(KA7)-,=:| >Q,=-V)`>?K:&L7Q)87*A7JP5`497?Pdw*P)*d-*h'Vv9JA8-:A7) )IA}7>R8: A7)()9@ complete blood count )`YIZ:W67(75P5`>A5,-P)8 A7);67*7:d-*%( (IZ P5` 45,=:%……•7+I9i@ /0==g/o012-13 A7)87(IY>Va:A7))IA}7?7()„7: mYJ-7@)89?AIZA7)i+'J7>4?<Z67ZIYP5`)I*&<)IA}7i:Z7*)7J^_=* @`A5879(8-%V A7)>()<J?h'Vv9J>Q,=->d'7)IZA7)87(IY)IA}7 >()<J?h'Vv9J>Q,=->d'7)IZA7)87(IY567%&'>R8:>Y<J9AIZh'Vv9J rectal procedentia :-A@7A:<W49) P:`:67>),=-*&7J)`Z7JR:KY(87*;<=i&8%9'i:)`+987*A7)87(IYP5`@67>Va:('-*47&7J)`Z7J>+587:<W%9'+5I* 87(IYi:)`J`>957+:_=* ^_=*V)`A-ZY'9J&7J&9:A)`>Q7`-7+7) &7J&9:Vq&&79` &7J:W67>A5,- (5-Y@: &7))`Z7J:W67>+5,-*;7*+:'7;'-*+),-&7Ji+'J7Z))>;7V9Y;7*%d&I:+5I*i:h'Vv9JZ7*)7J &67+)IZA7)87(IY low anterior resection P5`A7)87(IY abdominoperineal resection :IW:>Va: A7)87(IY5_Ai:-X'*>RK*A)7:^_=*i:)`+987*A7)87(IY?<m-A7&;67-I:()7J(8->&':V)`&7;;<=49Z4X?)`ZZA7) dIZx87JVq&&79` (neuraplexia) YI*:IW::KJ?P:`:67i+'47&7J&9:Vq&&79`i:h'Vv9JA5X8?:<W%9'>Va:>957-J87* :'-J 5 9I:+5I*87(IY >Q,=-)->957i+'>&':V)`&7;;<=mY:A)`;ZA)`P;A+),-Y_*)IW*i:)`+987*A7)87(IY YI*A5879…†‡:(I9&7?7)xA5IZ?7;67*7:%Y'(7?VA(K i:h'Vv9J;<=A'-:?`>)w*?<d:7Yi+j8+),-5XA57??7A+),--Jh8(=67?7A -7@('-*P:`:67987A7)87(IY-7@ ?<5(8-)`ZZV)`&7;;<=49Z4X?A7);67*7:d-*-9IJ9`>QM mYJ-7@;67i+'%?8?< erection +5I*A7)87(IY +),- >AKY>Va: retrograde ejaculation %Y' &89:i:>QM+jK*-7@;67i+'R8-*45-YP+'*^_=*%?8&8*5A)`;Z?7A:IA
- 10. 17 h'Vv9JZ7*)7J;<=@67>Va:('-*>d'7)IZA7)87(IY abdominoperineal resection :IW: h'Vv9JP5`j7(K 49)%Y')IZ467P:`:67>A<=J9AIZ;97)>;<J? >:,=-*@7Ah'Vv9J>+587:<W('-*x87J-X@@7)`;7*;97)>;<J?(5-YR<9K( mYJi+'497?&674Ij>),=-*A7)i+'497?)h'P5`i+'A675I*i@PA8h'Vv9J A7)87(IY?<+5IAA7)4,- (IY%&'()*&89:;<=>Va:?`>)w*P5`>:,W-567%&'Y<;<=-Jh8Y'7:Z:P5`587*(8-A'-: ?`>)w* )9?;IW*(8-?:W67>+5,-*Z)K>9[d'7*>4<J*--Ai+'+?Y -:_=*A7)87(IYm)4?`>)w*%&'()*?< 3 PZZ4,- - A7)87(IY anterior resection >+?7`&67+)IZh'Vv9J;<=QZA'-:?`>)w*Z)K>9[%&'()*&89:Z: >?,=-(IY 567%&'&89:;<=?<QJ7‚K&L7Q--AP5'9 &7?7)x:67567%&'&89:;<=>+:,-P5`587*(8-Z)K>9[;<=(IY--A?7>JwZ(8-567%&' >d'7+7AI: P5`)-J(8-d-*567%&'-Jh8>+:,-(8- anterior peritoneal reflection h'Vv9J&7?7)xx87J-X@@7)`;7* ;97)+:IA%Y' - A7)87(IY low anterior resection iR'A)[<;<=A'-:?`>)w*-Jh8Z)K>9[%&'()*&89:A57*+),-&89:587* )-J(8-d-*567%&'-Jh8i('(8- anterior peritoneal resection h'Vv9J&7?7)xx87J-X@@7)`;7*;97)+:IA%Y' -J87*%)Aw(7?Z7*4)IW*;<=)-J(8-567%&'-Jh8(=67?7A >R8:A7)87(IY extended low anterior resection with coloanal anastomosis14-15 ^_=*+?7Jx_*A7):67567%&'&89:Z:(8->d'7AIZ anal canal ;67i+'?<m-A7&>AKY )-J(8-567%&')I=9^_?%Y'*87J PQ;JN?IA:KJ?i+'h'Vv9Jx87J-X@@7)`;7*;97)>;<J?RI=94)79 (temporary ostomy +),- protective ostomy) >Va:)`J`>957V)`?7[ 3 >Y,-: >Q,=-i+'P:8i@987)-J(8-567%&'(KYY<P5`h'Vv9J…†‡: (I9@7AA7)87(IY4)IW*P)A @7A:IW:;67A7)87(IY>Q,=->AwZ;97)>;<J?i+'h'Vv9Jx87J-X@@7)`;7*;97)+:IA(8-%V - A7)87(IY abdominoperineal resection (APR)16 >5,-AiR'A)[<;<=A'-:?`>)w*-Jh8Z)K>9[%&'()* &89:587*i:)`J` 5 >^:(K>?()>+:,- anal verge +),-A)[<;<=A'-:?`>)w*5XA57?&h8A5'7?>:,W-d-*-X'*>RK*A)7: +),-A)[<;<=A5'7?>:,W-+h)hY;97)+:IA;67*7:ZAQ)8-* >Va:A7)87(IY>+?,-:A7)87(IYd'7*(': +7AP(8('-*(IY A5'7?>:,W-+h)hY;97)+:IA;IW*+?Y--AP5`>JwZV‰YK9+:I*Z)K>9[A':>d'7+7AI: ;67i+'h'Vv9J@67>Va:('-*x87J -X@@7)`;7*+:'7;'-*(5-YR<9K( (permanent colostomy) A7)YhP5i:)`J`+5I*A7)87(IY YhP5>R8:>Y<J9AIZA7)87(IY;<=('-*(IY(8-567%&'(7?VA(K mYJYhP5i+'&7J&9:A)`>Q7`-7+7);67*7: -Jh8>&?-A)[<;<=h'Vv9J;'-*-,Y?7A i+'J7VˆKR<9:`-J87*:'-JL7Ji:)`J` 24 RI=9m?*P)A:IZ@7A4)IW*P)A;<=i+' A8-:A7)87(IY >)K=?i+'h'Vv9J)IZV)`;7::W67P5`-7+7)>?,=-?<A7);67*7:d-*567%&'+),->?,=-?I=:i@987)-J(8- 567%&'(KYY< -:_=*i:h'Vv9J;<=%Y')IZA7)87(IY low anterior resection +),- abdominoperineal resection >:,=-*@7Ai:)`+987*A7)87(IY-7@A8-i+'>AKY-I:()7J(8->&':V)`&7;Z)K>9[-X'*>RK*A)7:;<=49Z4X?A7) ;67*7:d-*)`ZZdIZx87JVq&&79` YI*:IW:P:`:67i+'47&7J&9:Vq&&79`%9'-J87*:'-J 5 9I:
- 11. 18 /0=SMZ8=L1L678X=5 ^_=*PZ8*(7? American Joint Committee on Cancer (AJCC) gZIZ;<= 6 V€ Q.M. 2545 %Y'>Va: 4 )`J` mYJ?<)7J5`>-<JYYI*(8-%V:<W Primary tumor (T) TX primary tumor cannot be assessed T0 no evidence of primary tumor Tis carcinoma in situ: intraepithelial or invasion of lamina propria T1 tumor invades submucosa T2 tumor invades muscularis propria T3 tumor invades through the muscularis propria into the subserosa, or into non- peritonealized pericolic or perirectal tissues T4 tumor directly invades other organs or structures, and/or perforates visceral peritoneum Regional Lymph Nodes (N) NX regional lymph nodes cannot be assessed N0 no regional lymph node metastasis N1 metastasis in 1 to 3 regional lymph nodes N2 metastasis in 4 or more regional lymph nodes Distant Metastasis (M) MX distant metastasis cannot be assessed M0 no distant metastasis M1 distant metastasis
- 12. 19 Stage Grouping Stage T N M 0 Tis N0 M0 I T1 N0 M0 T2 N0 M0 IIA T3 N0 M0 IIB T4 N0 M0 IIIA T1-T2 N1 M0 IIIB T3-T4 N1 M0 IIIC Any T N2 M0 IV Any T Any N M1 -:_=*A7)PZ8*)`J`d-*m)4i:m)4?`>)w*%&'()*>+?,-:AIZA7)PZ8*)`J`d-*m)4i:m)4?`>)w*567%&'i+j8 +5I*A7)87(IY)IA}7P5`;)7Z5A7)()9@;7*QJ7‚K9K;J7V)`A-ZAIZ5A7)()9@;7* +'-*VˆKZI(KA7);<=%Y';67A8-:A7)87(IY ;67i+'&7?7)x;)7Z)`J`d-*m)4?`>)w*%&'()* mYJh'Vv9Ji:)`J`;<= 1 :IW:%?8@67>Va:('-*%Y')IZA7))IA}7>&)K?L7J+5I*A7)87(IY17-19 P(8i:h'Vv9J;<=%Y')IZA7)9K:K@gIJ987>Va:m)4?`>)w* 567%&'()*i:)`J`;<= 2 P5` 3 :IW:@67>Va:('-*%Y')IZA7)i+'J7>4?<Z67ZIYP5`A7)g7JP&*Z)K>9[-X'*>RK*A)7: >Q,=-5Ym-A7&A7)A5IZ>Va:^W67d-*m)4 &89:h'Vv9Ji:)`J`;<= 4 :IW:QK@7)[7i+'A7))IA}7mYJ467:_*x_*497? Pdw*P)*d-*h'Vv9J>Va:&674Ij
- 13. 20 Diseases of the anal canal /0123405678D20=NWg/1-3 anal canal 4,- 567%&'&89:;<=(8-@7A%&'()*mYJ>)K=?(':@7A pelvic diaphragm P5`&KW:&XYZ)K>9[ anal verge ?<497?J79V)`?7[ 4 >^:(K>?() -anatomical anal canal >)K=?@7A anal verge x_* dentate line -surgical anal canal >)K=?@7A anal verge x_* anorectal ring ^_=*>Va:d-Z587*d-*A5'7?>:,W- puborectalis P5`&7?7)x4567%Y'@7AA7)()9@;7*;97)+:IA mYJ anorectal ring -Jh8&h*A987 dentate line 1-1.5 >^:(K>?() anal verge >Va:)-J(8-)`+987* anoderm AIZ perianal skin anoderm >Va: squamous epithelium ;<=?<>&':V)`&7;@67:9:?7A P(8d7Y secondary skin appendage ^_=*%Y'PA8 hair follicle, sebaceous gland P5` sweat gland dentate line +),- pectinate line >Va: true mucocutaneous junction -Jh8Z)K>9[ 1-1.5 >^:(K>?() >+:,- anal verge )`J` 6-12 ?K55K>?()>+:,- dentate line >Va: transitional zone ^_=* squamous epithelium d-* anoderm >V5<=J:>Va: cuboidal P5` columnar epithelium i:;<=&XY anal canal xhA5'-?)-ZY'9JA5'7?>:,W-+h)hY;97)+:IAL7Ji: (internal sphincter) P5`A5'7?>:,W-+h )hY;97)+:IAL7J:-A (external sphincter) mYJA5'7?>:,W-+h)hY;97)+:IAL7Ji:>Va:A5'7?>:,W-^_=*(8-?7 @7A circular smooth muscle d-* %&'()*>Va: involuntary muscle A5'7?>:,W-+h)hY;97)+:IAL7J:-A V)`A-ZY'9J voluntary striated muscle 3 &89: 4,- subcutaneous, superficial P5` deep group Z)K>9[)`+987*A5'7?>:,W-+h)hY;97)+:IAL7Ji:P5`L7J:-A >)<JA987 intersphincteric plane >Va: fibrous tissue ^_=*(8-?7@7A longitudinal smooth muscle d-*%&'()* -7@>)<JA-<AR,=-+:_=*987 conjoined longitudinal muscle columns of Morgagni V)`A-ZY'9J mucosa ;<=+:7(I9d_W: V)`?7[ 8-14 -I: 97*(I9>+:,- dentate line Z)K>9[Y'7:587*)`+987* column of Morgagni P(85`-I:4,- anal crypt L7Ji: anal crypt V)`A-ZY'9J anal gland ^_=*QZ?7Ai:RIW: submucosa P5`?<;8-(KY(8->d'7%Vi: intersphincteric plane ()hV;<= 3)
- 14. 21 =BCDEF 3 /0123405678 anal canal2 =LMMNO7PQOR7PSP8 %Y')IZ@7A+5-Y>5,-YPY* inferior rectal ^_=*>Va:Pd:*d-*+5-Y>5,-Y PY* internal pudendal =LMMNO7PQOR7PPV0 - Z)K>9[ anal canal &89:Z:>;>d'7&h8+5-Y>5,-YY67 middle rectal ^_=*>;>d'7 +5-Y>5,-YY67 internal iliac >d'7&h8 caval system - Z)K>9[ anal canal &89:587*>;>d'7&h8+5-Y>5,-YY67 inferior rectal, +5-Y >5,-YY67 pudendal, +5-Y>5,-YY67 internal iliac P5` caval system (7?567YIZ =LMMNO7PWUV0QNOR78 - Z)K>9[>+:,-(8- dentate line >;>d'7&h8 superior rectal lymphatic >d'7&X8 (8-?:W67>+5,-* inferior mesenteric +),-(8-?:W67>+5,-* internal iliac - Z)K>9[(=67A987 dentate line >;>d'7&h8(8-?:W67>+5,-* inguinal P5`(8-? :W67>+5,-* inferior +),- superior rectal =LMMC=L:0D - A5'7?>:,W-+h)hY;97)+:IAL7Ji:?<>&':V)`&7;;IW*)`ZZ sympathetic P5` parasympathetic 4-J49Z4X?i+'>AKYA7)Z<ZP5`457J(I9d-*A5'7?>:,W-+h)hY;97)+:IA - A5'7?>:,W-+h)hY;97)+:IAL7J:-AP5`A5'7?>:,W- levator ani ?<>&':V)`&7; inferior rectal branch d-* internal pudendal nerve (S2, S3, S4) P5` perineal branch d-* S4 ?7 49Z4X? anal canal ;<=-Jh8(=67A987 dentate line &7?7)x)IZ497?)h'&_A&I?I& )'-: >Jw: V9Y%Y'@7AA7)?< >&':V)`&7; pudendal ?7>5<WJ* d[`;<=Z)K>9[;<=>+:,-(8- dentate line %?8?<>&':V)`&7;)IZ497?)h'&_A
- 15. 22 :=E=23D106789:;<=83-5 defecation +),-A7)dIZx87J-X@@7)` ^_=*@67>Va:('-*-7MIJA7);67*7:)89?AI:d-*%&'()* P5` anal canal >?,=--X@@7)`>45,=-:>d'7&h8%&'()* ;67i+'%&'()*dJ7J>AKY reflex ;67i+'A5'7?>:,W-+h)hY;97)+:IAL7Ji: P5`L7J:-A457J(I9 >Q,=-dIZ-X@@7)`--A&h8L7J:-A)87*A7J -J87*%)Aw(7?)87*A7J4:>)7&7?7)xA5IW: -X@@7)`%Y' (continence) mYJA7)ZI*4IZA5'7?>:,W-+h)hY;97)+:IAL7J:-Ai+'Z<Z(I9 %?8i+'-X@@7)`>5wY)-Y --A?7 incontinence +?7Jx_*L79`;<=%?8&7?7)x49Z4X? rectal content %Y' ;67i+'?<-X@@7)`;<=>Va: d-*Pdw* d-*>+59 +),-A7^>5wY)-Y--A?7 -7@>AKY@7A mechanical defect d-*A5'7?>:,W-+h)hY;97)+:IA +),-)`ZZV)`&7;;67*7:KYVA(K X=5DEFYMMZ71678D20=NWg/ Hemorrhoids20-24 W310] m)4)KY&<Y9*;97) +?7Jx_* symptomatic sliding anal cushion Y10k323D10/0123405 anal cushion V)`A-ZY'9J mucosa ;<=+:7(I9d_W:?7 L7Ji:?<+5-Y>5,-YY67 +5-Y>5,-YPY* elastic connective tissue P5`A5'7?>:,W->)<JZ mYJ anal cushion @`QZi+j8|-Jh8 3 -I:i:(67P+:8*;<= P:8:-:4,- 3, 7 P5` 11 :7žKA7 (mYJ(67P+:8* 12 :7žKA7 4,- pubic symphysis) -J87*%)Aw(7?-7@?< cushion >5wA| -Jh8)`+987* main cushion %Y' >:,=-*@7A cushion >Va:&89:;<=:h:d_W:?7L7Ji: anal canal YI*:IW:>?,=- cushion xhAY_*)IW*@:PZ: )7Z@`>Va:A7)>QK=?d:7Y497?A9'7*d-* lumen d-* anal canal ;67i+'-X@@7)`A'-:i+j8&7?7)x87:%V%Y' mYJ%?8>AKYA7)g<Ad7Yd-* mucosa i:L79` straining @7AA7)>Z8*x87J-X@@7)` >:,=-*@7A-X@@7)`A'-:i+j8+),-Pdw* ;67i+' cushion >AKYA7)>5,=-:(I95*?7 @:A5'7?>:,W->)<JZ;<=J_Y anal cushion (TreitzŸs muscle) g<Ad7Y P5` cushion J,Y J79@: prolapse --A?7 :-A@7A:<WL79` straining P5`A7)-Jh8KY(67P+:8*d-* cushion >Va:5;67i+' >AKY engorgement P5` congestion ;67i+' mucosa ;<=VA45X?>&':>5,-YJ,Y--AZ7*5* >AKYA7)g<Ad7Y >5,-Y--A%Y'*87J>957x87J-X@@7)` anal cushion ;<=?<QJ7‚K&L7Q@:>AKY-7A7)YI*A5879:<W>)<JA987m)4 )KY&<Y9*;97)^_=*@67>Va:('-*%Y')IZA7))IA}7 &7>+(X;<=P;'@)K*d-*m)4)KY&<Y9*;97)JI*%?8;)7Z P(8QZ987&I?QI:‚NAIZA7)>Z8*x87J)X:P)*P5`>),W-)I* P5'9 A7)?<>5,-Y4I=*i:>&':>5,-YY67;<=:I* anal canal ^_=*QZ%Y'i:L79`(IW*4))LN P5`J,::7:%Y'
- 16. 23 &7?7)x@67P:A)`J`d-*m)4)KY&<Y9*;97)%Y'YI*(8-%V:<W 1. internal hemorrhoid ()KY&<Y9*;97)L7Ji:) 4,-)KY&<Y9*;97);<=-Jh8>+:,- dentate line VA45X? mYJ mucosa PZ8*--A%Y'>Va: 4 )`J`4,- )`J`;<= 1 +I9)KY&<Y9*;97)JI*4*-Jh8L7Ji:;97)+:IA ?<-7A7)>5,-Y--A>Q<J*-J87*>Y<J9 )`J`;<= 2 +I9)KY&<Y9*J'-J--A?7:-A;97)+:IA>957>Z8* P5`A5IZ>d'7%V%Y'>-*>957+JXY>Z8* )`J`;<= 3 +I9)KY&<Y9*J'-J--A?7>957>Z8* P5`%?8A5IZ>d'7%V>-*('-*YI:A5IZ@_*@`>d'7 )`J`;<= 4 +I9)KY&<Y9*m(?7AP5`J'-J--A?7-Jh8:-A;97)+:IA(5-Y>957 2. external hemorrhoid ()KY&<Y9*;97)L7J:-A) 4,-)KY&<Y9*;97);<=-Jh8(=67A987 dentate line 3. combined (mixed) hemorrhoid +?7Jx_*h'Vv9J;<=?<;IW*)KY&<Y9*;97)L7Ji:P5`L7J:-A 70/0=:V05gsD085O3W3/ ?<YI*(8-%V:<W 1. x87J>Va:>5,-Y&<PY*&Y+JY(7?+5I*A7)x87J-X@@7)` >5,-Y>45,-Z>:,W--X@@7)` 2. A'-:V5KW:--A?7:-A;97)+:IA>957x87J-X@@7)` 3. A':Pg`P5`4I: QZ>?,=-)KY&<Y9*J'-J--A?7;67i+'?<>?,-A>V†‡-:d-Z;97)+:IA-Jh8>&?- 4. ?<A'-:--A?747-Jh8L7J:-A;97)+:IA ;67i+'>AKY-7A7)V9Y >:,=-*@7A>AKY acute thrombosis d_W:i:A'-:)KY&<Y9*;<=J'-J--A?7P5`xhA+h)hYd-*;97)+:IA)IY%9'>AKY strangulated hemorrhoid /0=23W3fmg1S1/X=5 1. anal fissure 2. infective diarrhea 3. malignancy of the anal canal 4. rectal prolapse ^_=*A7)PJAm)4)KY&<Y9*;97)--A@7Am)4-,=:;67%Y'mYJA7)^IAV)`9I(K()9@)87*A7J A7)Yh5IA}[` d-*A'-: A7)()9@;97)+:IAY'9J:KW9?,- P5`A7)iR' anoscopy -J87*%)Aw(7?i:4:&h*-7JX;<=QZ>5,-Y--A ;7*;97)+:IA @67>Va:('-*%Y')IZA7)()9@>QK=?>(K?Y'9JA7);67A7)&8-*A5'-*567%&'i+j8 (colonoscopy) +),- A7)>-A^>)JN&9:PV•*;7*;97)+:IA (barium enema) >:,=-*@7A-7@QZ>:,W-*-A567%&')89?AIZ)KY&<Y9*;97) %Y' /0==g/o0 )KY&<Y9*;97)L7Ji:)`J`;<= 1 P5`2 P:`:67i+'iR' medical therapy mYJYhP5A7)dIZx87Ji+'>Va:%V (7?V)A(K %?8i+';'-*hA+),-;'-*>&<J;<=;67i+'('-*>Z8*x87J?7A Y,=?:W67i+'>Q<J*Q->Q,=-i+'-X@@7)`:K=?5* )IZV)`;7:IAP5`5%?' +),-iR'J7>QK=?A7A-7+7)R89Ji+'-X@@7)`>Va:A'-:x87J%Y'&`Y9Ad_W: YhP5&Xd-:7?IJ Z)K>9[;97)+:IAi+'&`-7Y +?I=:--AA675I*A7J&?=67>&?- ;67@K(i@i+'P@8?i& >Q,=-i+'A7)Z<Z(I9d-*567%&' >Va:%V(7?V)A(K +7A)IA}7%VP5'9 2 &IVY7+N -7A7)%?8Y<d_W: P:`:67i+')IA}7>QK=?>(K?mYJ
- 17. 24 1. rubber band ligation mYJiR'>4),=-*?,-@IZP5`)IYdIW9d-*)KY&<Y9*;97) ;67i+'+I9)KY&<Y9* ;97) v- (necrosis) P5`+5XYL7Ji: 7-10 9I: %Y'5Y<i:)KY&<Y9*;97))`J`;<= 2 P5` 3 Z7*)7J 49))IY >+:,- dentate line >:,=-*@7A%?8?<>&':V)`&7;)IZ)h'497?)h'&_A>@wZV9Y ;67%Y'4)IW*5` 1-3 +I9 ;67^W67%Y';XA 4-6 &IVY7+N +'7?;67i:h'Vv9JLh?K('7:;7:(=67>:,=-*@7A;67i+'(KY>R,W-i:A)`P&>5,-Y%Y' +),-+7A@67>Va:49)i+'J7 VˆKR<9:`)89?Y'9J i:A)[<;<=h'Vv9JAK:J7V•-*AI:A7)Pdw*(I9d-*>5,-Y('-*+JXYJ7A8-: 1 &IVY7+NP5` 2 &IVY7+N+5I*A7))IA}7Y'9J9K‚<:<W 2. sclerotherapy mYJA7)g<Y 5% phenol i::W67?I:?`A-A g<YZ)K>9[+I9)KY&<Y9*i:RIW: submucosa mYJ)`9I*%?8i+'>d'7%Vi:>&':>5,-Y J7;67i+'>AKYVˆKAK)KJ7A7)-IA>&ZP5`>AKYQI*,Y)IY;67i+'>&': >5,-YJXZ5* g<Y^W67%Y';XA 2 &IVY7+N %Y'5Y<i:)KY&<Y9*;97))`J`;<= 1 P5` 2 3. cryotherapy iR'>4),=-*;<=?< nitrogen >+59 +),- A¢7^ N2O ;<=?<497?>Jw:@IY ;67i+'+I9 )KY&<Y9*A57J>Va::W67Pdw*P5` v-5*i:;<=&XY %?8:KJ?iR'i:Vq@@XZI:>:,=-*@7A;67i+')`47Jd-Z;97)+:IAP5`?< :W67>+5,-*^_??7A 4. infrared photocoagulation iR')I*&< infrared @<WZ)K>9[+I9)KY&<Y9*V)`?7[ 1.5 9K:7;< )9? 3 4)IW* ;67i+'mV)(<:i:>^55NPdw*(I9P5`>^55N(7Ji:;<=&XY >+?7`i:)KY&<Y9*;97))`J`;<= 1 P5` 2 5. bipolar current therapy mYJA7)iR'@<W%……•7@<W;<=+I9)KY&<Y9* %?8:KJ?iR'>:,=-*@7AiR'>957 i:A7)87(IY:7: 6. hemorrhoidectomy A)[<>Va:)`J`;<= 3 P5` 4 combined hemorrhoid P5` acute thrombosed incarcerated hemorrhoid ;67%Y'+57J9K‚< mYJ?<+5IAA7)4,- A7)(IY>-7)KY&<Y9*;97)--A mYJ-7@>JwZV‰YP5+),-%?8Aw%Y'd_W:AIZPQ;JNh'87(IY i:Vq@@XZI:?<A7)QI¤:7>4),=-*?,-(IYP5`>JwZ)KY&<Y9* ;97)&67>)w@)hV (staple hemorrhoidectomy) -J87*%)Aw(7?&7?7)x:67?7iR')IA}7)KY&<Y9*;97)L7Ji: >;87:IW: )KY&<Y9*;97)L7J:-A)IA}7mYJA7)87(IY hemorrhoidectomy P(8+7AA57J>Va: skin tag P5'9 +7A%?8i+j8?7A+),-%?8A8-i+'>AKYVqj+7 %?8@67>Va:('-*87(IY)IA}7 A)[< thrombosed external hemorrhoid ;<=h'Vv9J?7QZPQ;JN+5I*?<-7A7)i:)`J`>957:'-JA987 48 RI=9m?* ?IA?<-7A7)V9Y?7A P:`:67i+';67A7)87(IY hemorrhoidectomy ;I:;< +7A>AK: 48 RI=9m?* -7A7)V9Y?IA5Y5*?7A P:`:67i+'iR' medical therapy +),-87(IYi:>957(8-?7 A7)YhP5i:)`J`+5I*A7)87(IY +5I*A7)87(IY)IA}7MI5JPQ;JNmYJ&89:i+j8 P:`:67i+'h'Vv9JPR8A':Y'9J:W67-X8: (warm sitz bath) ;XA9I: 9I:5` 2 - 3 4)IW* 4)IW*5` 10-15 :7;< >Q,=->QK=?A7)%+5>9<J:>5,-Y ;67i+'P587(IYJXZZ9? P5` Z))>;7-7A7)V9Y )9?;IW*>Va:A7);67497?&`-7YP5 )IZV)`;7:-7+7);<=?<A7A +),-J7>QK=?A7A-7+7) P5`Y,=?:W67(7??7A|
- 18. 25 402LSD=/t;7WNOg8/0=uZ0<gP L79` urinary retention >Va:L79`P;)A^'-:+5I*87(IY;<=QZ%Y'Z8-J;<=&XY P:`:67i+'V•-*AI:mYJi+' h'Vv9JVq&&79`A8-:>d'7)IZA7)87(IY i+'&7):W67%?8>AK: 250 ?K55K5K()i:d[`87(IY i+'J7Z))>;7V9Yi+' >Q<J*Q- +7AVq&&79`%?8--Ai+'&9:Vq&&79` L79`>5,-Y--A;7*;97)+:IA+5I*87(IY QZ%Y')'-J5` 1 +7A>AKYi:)`J`P)A+5I*A7)87(IY?IA>AKY @7A raw surface +7A?<>5,-Y--A%?8?7A?IA+JXY%Y'>-* P(8+7A?<>5,-Y--A?7A ?IA>AKY@7AA7)+'7?>5,-Y %?8Y< @67>Va:('-*:67h'Vv9J>d'7%V+'7?>5,-Yi:+'-*87(IY P(8+7A>5,-Y--A;7*;97)+:IA>AKYi:)`J` 7-10 9I:+5I*87(IY?IA>AKY@7A7)(KY>R,W-;<=P587(IY P:`:67i+')IA}7497?&`-7Y P5`i+'J7VˆKR<9:` +7A?< >5,-Y--A?7A('-*:67h'Vv9J>d'7+'-*87(IY >Q,=-&67)9@P5(8-%V Anal fissure25-28 W310] m)4P5d-Z;97)+:IA 4,-P5i:P:9J79Z)K>9[d-ZV7A;97)+:IA (mucocutaneous junction) @7Ai(' dentate line @:x_* anal verge ?IAQZ;<=Z)K>9[ posterior +),- anterior midline ?7AA987 Y'7:d'7* Y10k3:=E=23D10 >R,=-987>AKY@7A9*@)>59)'7J A7);<=?< internal anal sphincter tone &h*d_W:@:A5'7?>:,W-+h)hY;97) +:IA(_*(I9 (spasm) ;67i+'-X@@7)`567Z7AP5`-X@@7)`Pdw* ^_=*-X@@7)`Pdw*@`4)hYAIZd-ZV7A;97)+:IA @:>AKYP5g<Ad7YP5`V9Y+5I*A7)x87J-X@@7)` ;67i+' sphincter tone &h*d_W: h'Vv9J%?8-J7Ax87J-X@@7)` >:,=-*@7AA5I9V9YP5`-X@@7)`Pdw*(7??7 :-A@7A:<W sphincter tone ;<=&h*d_W:;67i+' anodermal blood flow 5Y5*mYJ>gQ7`Z)K>9[ posterior commissure >Va:&7>+(X;<=;67i+'QZ anal fissure ;<=Z)K>9[ posterior midline ?7A;<=&XY 70/0=D085O3W3/ h'Vv9J-Jh8i:9IJ+:X8?&79+),-i:9IJA57*4: >QM+jK*QZ?7AA987>QMR7J>5wA:'-J ?<-7A7)>@wZV7A ;97)+:IAmYJ>gQ7`-J87*JK=*>957x87J-X@@7)` -7A7)V9Y@`4*-Jh8(8-%V-<A 10-20 :7;< +),-:7:>Va: RI=9m?* mYJ>gQ7`i: acute fissure &89:i:A5X8? chronic fissure h'Vv9J-7@?<-7A7)x87J-X@@7)`?<>5,-Y&Y>5wA:'-J ^_?(KYA)`Y7} R67)` -7@?<(K=*>:,W-Z)K>9[V7A;97)%Y' ()9@)87*A7J@`QZP5;<=d-ZV7A;97) &89:Z:d-*P5?<(K=*>:,W- >)<JA hypertrophic anal papilla P5`(K=*>:,W-Z)K>9[d-Z587*d-*P5>)<JA987 sentinel pile
- 19. 26 /0=23W3fmg1S1/X=5 PJAAIZP5@7Am)4-,=:| >R8: >)K? ^K…‰5K& 9I[m)4 P5`?`>)w*;97)+:IA mYJ>gQ7`i:A)[<;<=)IA}7 xhA('-*P(8%?8+7J +),->Va:Y'7:d'7*+57J(67P+:8* /0==g/o0 1. acute fissure i+'A7))IA}7PZZV)`4IZV)`4-*-7A7) &K=*&674Ij;<=&XY4,-A7)%?8i+';'-*hA >Q,=- A67@IY9*@)>59)'7J mYJi+'J7)`Z7J J7Z))>;7V9Y A7)PR8A':Y'9J:W67-X8: ^_=*>R,=-987;67i+' resting anal pressure 5Y5* >QK=?A7)%+5>9<J:>5,-Y R89J457JA5'7?>:,W-+h)hY ;67i+'5Y-7A7)V9YP5`P5+7J &89: i+j8P5?IA+7JL7Ji: 3 &IVY7+N+5I*)IA}7 +7A%?8+7JP:`:67i+')IA}7>+?,-: chronic fissure 2. chronic fissure )IA}7mYJA7)87(IY;67 lateral internal sphincterotomy >Va:9K‚<;<=Y<;<=&XYi: Vq@@XZI: 4,-A7)(IYA5'7?>:,W-+h)hY;97)+:IAL7Ji:--AZ7*&89:;<=Z)K>9[ 3 +),- 9 :7žKA7 )9?;IW*?<A7):67J7+57JR:KY>R8: A5X8? nitric oxide donor, calcium channel agonist +),- botulinum toxin ?7iR'i:A7))IA}7 -J87*%)Aw(7?5A7))IA}7Y'-JA987A7)87(IY29-30 402LSD=/t;7WNOg8/0=uZ0<gP 1. postanal abscess Z)K>9[;<=;67 sphincterotomy ^_=*A57J>Va: fistula in ano i:>957(8-?7 2. hematoma @7AA7)+'7?>5,-Y%?8Y< 3. urinary retention 4. unheal ulcer +),- recurrent QZ%Y')'-J5` 1-7 @7AA7);67A7)87(IY%Y'%?8&?Zh)[N P:`:67i+' 87(IY^W67Y'7:()*d'7? Anorectal abscess31-33 Y10k3:=E=23D10 m)4 €4I[¥&h()gIZQ5I: >Va: €Z)K>9[;97)+:IAP5`PA'?A': ?<&7>+(X&89:i+j8@7AA7)(KY>R,W-i: anal gland (cryptoglandular infection) ;67i+'>AKY €+:-*d_W:i: intersphincteric plane €+:-*:<W A)`@7J%V(7? conjoined longitudinal ligament &h8R8-*(87*| (anorectal abscess) P5`-7@P(A--A&h8 K9+:I*Z)K>9[d'7*;97)+:IA mYJ anorectal space ;<=+:-*A)`@7J%V V)`A-ZY'9J - perianal space QZ?7A;<=&XY - intersphincteric space - submucous space - ischiorectal space - superficial postanal space
- 20. 27 - deep postanal space - supralevator space - retrorectal space =BCDEF 5 S:P8 anorectal abscess xW3P<Z08c32 70/0=D085O3W3/ -7A7)V9Y>Va:-7A7);<=QZ%Y'Z8-J;<=&XY A7)>YK: %- +),->Z8*;67i+'V9Y>QK=?d_W: -7@4567%Y'A'-:AY >@wZd'7*;97)+:IA Z7*)7J?<%d' Vq&&79`567Z7A+),-(KY>R,W-i:A)`P&>5,-Y i: abscess Z7*R:KY >R8: ischiorectal abscess -7@%?8?<@XYAY>@wZRIY>@: P(8h'Vv9J-7@?<-7A7)V9Y5_A|Z)K>9[d'7*;97)+:IA (5-Y>957 abscess ;<=>AKYd_W: -7@>AKY%Y'?7AA987 1 space >R8:i: horseshoe abscess >AKY@7A+:-*i: deep postanal space A)`@7J%V;<= ischiorectal space ;IW* 2 d'7* /0==g/o0 ;67A7))`Z7J+:-*mYJ>)w9;<=&XY J7VˆKR<9:`?<;<=iR'i:Z7*A)[<>R8: extensive cellulitis, immunocompromise >R8:>Z7+97: m)45KW:+I9i@)I=9 +),->-Y&N>Va:(': A7))`Z7J+:-*;67i+'h'Vv9J +7Jd7Y%Y')'-J5` 50 ;<=>+5,-@`A57J>Va: anal fistula i:>957(8-?7 YI*:IW:A7))`Z7J+:-*49);67i+' iA5')h;97)?7A;<=&XY >Q,=-i+' tract d-* fistula &IW:;<=&XY Fistula in ano31-34 fistula 4,- abnormal communication )`+987* epithelial 2 R:KY;<=(87*AI:
- 21. 28 fistula in ano +),- €4I[¥&h()>),W-)I* 4,-A7)>R,=-?(8-)`+987* anal canal P5` perianal skin mYJ &89:i+j8>Va: chronic form d-* cryptoglandular infection P(8-7@>AKY@7Am)4-,=:| >R8: carcinoma, radiation, trauma +),- actinomycosis %Y' 70/0=D085O3W3/ ?<+:-*%+5@7A)h>V‰Yd-* €>),W-)I*;IW* internal P5` external opening -7@4567%Y' tract ;<= >R,=-?(8-)`+987* internal P5` external opening i:Z7*)7J +),-QZ internal opening @7A anoscopy Goodsall's rule &7?7)x:67?7iR'i:A7)+7(67P+:8* internal opening %Y' mYJA5879987 +7A external opening -Jh8i:)`J`%?8>AK: 3 >^:(K>?() @7A anal verge P5'9 external opening ;<=-Jh8Y'7:+:'7 @`?< tract P5` internal opening QX8*()*>d'7+7 anal verge +7A external opening -Jh8Y'7:+5I* tract P5` internal opening @`>V‰Y>d'7&h8Z)K>9[ posterior midline -J87*%)Aw(7?h'Vv9JZ7*)7JAw%?8()*(7? GoodsallŸs rule ()hV;<= 6) =BCDEF 6 S:P8 GoodsallHs rule33 /0==g/o0 +5IAA7))IA}74,- A7))IA}7L79`(KY>R,W- mYJ>AwZA5'7?>:,W-+h)hY;97)+:IA%9'i+'%Y'?7A;<=&XY ;67%Y' +57J9K‚<4,- 1. fistulotomy 4,-A7)>V‰Y fistula tract --AP5`dhY+),-@<W epithelium ;<=ZX tract P5'9)-i+'P5 +7JmYJ secondary intention 2. fistulectomy 4,-A7)87(IY>-7 fistula tract --A;IW*+?Y P(8?<d'->&<J4,-('-*(IY>-7 external sphincter ;<=+X'?)-Z fistula tract --A%VQ)'-?AI: ;67i+'>AKY incontinence %Y'
- 22. 29 3. seton procedure 4,-A7)iR' suture material 45'-* fistula tract %9' P5'948-J|Y_*)IYi+' muscle 48-J| necrosis P5`>AKY fibrosis R'7| R89J5YL79` incontinence %Y' iR'A)[<;<= tract A9'7*+),- 45X?A5'7?>:,W-+h)hY;97)+:IA?7A +),-i&8%9'>Q,=-V)`mJR:Ni:A7))`Z7J+:-*)`+987*)-i+'P5+7J 4. anorectal advancement flap 4,-A7):67 mucosa P5`A5'7?>:,W-Z7*&89:?7>JwZV‰Y internal opening Sexual transmitted disease m)4(KY(8-;7*>QM&I?QI:‚XN;<=QZ%Y'Z8-Ji:Vq@@XZI:4,- condylomata acuminata (condyloma acuminatum)35-36 >Va:+hY>AKY@7A human papilloma virus i:h'+jK*?IA57??7@7A)-Jm)4i:R8-*45-Y &89:i:h'R7J>AKY@7AA7))89?>QM;7*;97)+:IA 70/0=D085O3W3/ QZ)-Z|;97)+:IA;IW*Y'7:i:P5`Y'7::-A )9?;IW*;<=-9IJ9`>QM mYJ>AKY>Va:(X8?>5wA|+57J|(X8?m( d_W:45'7J+I9Y-AA`+5=67 (8-?7m(d_W:>d'7?7RKYAI:>Va:A'-:>Y<J9 ?<:W67>+5,-*^_? K9;<=>V)7`+5XY*87J>?,=-?< A7)A)`;ZA)`P;A;67i+'?<>5,-Y--A Z)K>9[)-Z|@`Pg`-Jh8>&?- -7@4I:)89?Y'9J ('-*PJAm)4@7A squamous cell carcinoma, fistula in ano +),-^K…‰5K& /0==g/o0 1. ;7Y'9J bichloroacetic acid +),- 25% podophyllin ;XA&IVY7+N(KY(8-AI:>Va:>957:7:@:+7J ^_=*?IA%?8%Y'5>:,=-*@7A%?8)IA}7)-Jm)4i:;97)+:IA%Y' P5`h'Vv9J?IA;'-i@AIZA7))IA}7>Va:>957:7:@: +JXY)IA}7%Vi:;<=&XY 2. excision +),- electrocoagulation >Va:9K‚<;<=Y<i:Vq@@XZI: 3. @<WY'9J carbon dioxide lasers +),- cryotherapy %Y'5Y< P(8('-*iR'>4),=-*?,-)747PQ* 4. interferon +),- immunotherapy >Q,=->&)K?&)'7*Lh?K4X'?AI:('7:>R,W-%9)I& >R8: imiquimod 5. antineoplastic preparation >R8: 5-FU, bleomycin Neoplasm of anal canal37-38 m)4?`>)w*Z)K>9[;97)+:IAQZ%Y'%?8Z8-J mYJ-7A7)&674Ij;7*45K:KA?IA45'7JAIZm)4?`>)w*%&'()* P(8h'Vv9J?IA?<-7A7)V9Y;97)+:IA)89?Y'9J >:,=-*@7A?`>)w*5XA57?x_*Z)K>9[;<=(=67A987 dentate line YI*:IW: i:h'Vv9JZ7*)7J%?8&7?7)x()9@)87*A7J;7*;97)+:IA;<=+'-*()9@h'Vv9J:-A%Y' -7@('-*i+'J7Z))>;7V9Y +),-@67>Va:('-*i+'J7:-:+5IZi:A7)+JKZRKW:>:,W->Q,=-&8*()9@;7*QJ7‚K9K;J7 &7?7)xQZm)4?`>)w*;97)+:IA%Y'+57JR:KY4,- - squamous cell carcinoma QZ>Va:P5d-Z:h:Pdw* ?<>5,-Y--A +),->Va:A'-: V9Y4I: x87J -X@@7)`%?8&XY ?IAA)`@7J%V;<=(8-?:W67>+5,-*Z)K>9[d7+:<Z i:R8-*;'-*P5`(IZ ?<497?&I?QI:‚NAIZ
- 23. 30 condylomata acuminata +),- chronic fistula in ano )IA}7mYJA7)i+'J7>4?<Z67ZIYP5`g7JP&* P5'9Yh A7)(-Z&:-* x'7(-Z&:-*Y<%?8('-*87(IY P(8x'7?<A'-:?`>)w*+5*>+5,--Jh8('-*87(IY--A Z7*4)IW*-7@ @67>Va:('-*;67 abdominoperineal resection - adenocarcinoma >AKY@7A anal gland >-* +),-5XA57?@7A%&'()* -7@QZPQ;JNY'9J € 4I[¥&h()>),W-)I* )IA}7mYJA7)87(IY abdominoperineal resection )89?AIZJ7>4?<Z67ZIYP5`g7JP&* - malignant melanoma QZ:'-J >Va:iA5' dentate line -7@?<&<+),-%?8?<&<;67i+'9K:K@gIJKY>Va:m)4 -,=:%Y' )IA}7mYJA7)87(IY -J87*%)AwY<>:,=-*@7A>Va:m)4;<=QZ:'-JP5`A7)QJ7A)[Nm)4%?8Y< @_*-7@)IA}7 Y'9JA7);67 radical surgery 4,-A7)87(IY;67 abdominoperineal resection +),-A7)(IY>gQ7`A'-:?`>)w* --A (local excision)