surgical rectal disorder

1. Disorders OF RETUM
DR.BEZAN BALOCH
ASSISTANT PROFESSOR

2. Anatomy of the rectum
●● The rectum measures approximately 15 cm in length
●● It is divided into lower, middle and upper thirds
●● The blood supply consists of superior, middle and
inferior
rectal vessels
●● The lymphatic drainage follows the blood supply. The
principal
route of drainage is upwards along the superior rectal
vessels
to the para-aortic nodes, although the lower rectum can
drain
to lymphatics along the lateral pelvic side walls

3. Main symptoms of
rectal disease
●● Fresh bleeding per rectum
●● Altered bowel habit with
loose stool
●● Mucus discharge
●● Tenesmus
●● Prolapse
●● Proctalgia (pain

4. Examination of the rectum
●● Visual inspection of the perineum
●● Digital examination
●● Proctoscopy
●● Sigmoidoscopy – rigid and/or
flexible

6. INJURIES
The rectum or anal canal may be injured in a number of
ways,
all of which are uncommon:
●● by falling in a sitting posture onto a pointed object;
●● penetrating injury (including gunshots) to the buttocks;
●● sexual assault or sexual activity involving anal
penetration;
●● by the fetal

8. Injuries to the rectum are serious and
invariably require
surgery
●● A temporary colostomy is often
necessary
●● There is a serious risk of associated
necrotising fasciitis, and
broad-spectrum antibiotics are mandatory
●● There may be associated bladder or
urethral damage

9. Rectal prolapse
●● It may be mucosal or full thickness
●● If full thickness, the whole wall of the rectum is included
●● It commences as a rectal intussusception
●● In children, the prolapse is usually mucosal and should
be
treated conservatively
●● In the adult, the prolapse is often full thickness and is
frequently associated with incontinence
●● Surgery is necessary for full-thickness rectal prolapse
●● The operation is performed either via the perineum or
via the
abdomen

11. Treatment
Surgery is required for full-thickness rectal
prolapse, and
the operation can be performed via a perineal or
abdominal
approach.
Abdominal operations can be by an open or
laparoscopic
approach.

12. PERINEAL APPROACH
These procedures have been used most frequently:
●● Thiersch operation. In this procedure, a steel wire, or silastic
or nylon tape, is placed around the anal canal. It has
become largely obsolete owing to problems with chronic
perineal sepsis, anal stenosis and obstructed defaecation.
●● Delorme’s operation. In this procedure, the rectal mucosa
is stripped circumferentially from the rectum over the
length of prolapse
Altemeier’s procedure. In this procedure, the rectum
is prolapsed through the anal canal and a full-thickness
resection performed, incorporating any associated colonic
prolapse. Restoration of colorectal continuity can be performed
by either a hand-sewn or stapled anastomosis.
This is the procedure of choice in patients presenting
with incarcerated and strangulated prolapse. It is a good
alternative perineal procedure to the Delorme’s operation,
particularly following recurrence.

13. ABDOMINAL APPROACH
The principle of all abdominal operations
for rectal prolapse
is to fix the rectum in its normal
anatomical position. Many
variations have been described, including
inserting a sheet
of polypropylene mesh between the
rectum and the sacrum

16. Proctitis
●● May be non-specific or related to a specific infective agent
●● Non-specific proctitis usually remains confined to the distal
bowel, but can involve the proximal colon
●● Symptoms include defaecatory frequency, loose stools,
bleeding and tenesmus
●● Endoscopic assessment with biopsy is required to establish
the diagnosis
●● Treatment usually involves medical management
Ulcerative proctocolitis
Proctitis due to Crohn’s disease
Tuberculous proctitis
Gonococcal proctitis
Bacllary dysentery

17. RECTAL POLYPS
The rectum, along with the sigmoid colon, is the most
frequent
site of polyps (and cancers) in the gastrointestinal
tract. Adenomatous polyps of the colon and rectum have
the
potential to become malignant. The chance of developing
invasive cancer is enhanced if the polyp is more than 1
cm
in diameter. Removal of all polyps is recommended to
allow
complete histological diagnosis and exclude carcinoma.
This
is best done using endoscopic biopsy or snare
polypectomy
techniques.

18. Rectal carcinoma

19. colorectal cancer is the second most common
malignancy, affecting more than 1 million people every year
and resulting in around 715,000 deaths. It is the second most
common cancer in women and the third most common cancer
in men, being the fourth most common cause of cancer
death after lung, stomach, and liver cancer.
Risk factors include Genetics,diet, alcohol, obesity, smoking and lack
of physical exercise. Most colorectal cancers are due to old age,
with around 60% of cases affecting patients 70 years or older

20. Pathologial types
Annular
Polypoidal
Ulceratve
Diffuse
colloid

21. Clinical features
Constipation
Bleeding per rectum
Early morning spurious diarrhea
Tenesmus
Loss of appetite

22. ABCDEF of carcinoma rectum
Altered bowel habits
Bleeding per recum
Constipation
Defaecaton incomplete
Early morning diarrhea
Fatigue weight loss

23. examination
DRE-90 % case can be diagnosis
Gowth in rectum
How many cm from annal verge
Ulcer, annular,nodular
Induraion, fixity,to surrounding structures
Blood stain on finer tip
Female patient vaginal examination
Abdominal examination for liver metastasis

24. Differential diagnosis
Villous adenoma
Proctitis
Amoebic granuloma
Tuberculous proctitis
Endometrioma

25. Diagnosis and assessment of rectal cancer
All patients with suspected rectal cancer should undergo:
● Digital rectal examination
● Full colorectal visualisation preferably by colonoscopy with
biopsy or computed tomography (CT) colonography or barium
enema
All patients with proven rectal cancer require staging by:
●● Imaging of the chest, abdomen and pelvis, preferably by CT
●● Local pelvic imaging by magnetic resonance imaging and/or
endoluminal ultrasound

26. spread
Local
Lymphatics
Blood
peritoneal

27. staging
Dukes’ staging
●● A: The growth is limited to the rectal wall (15%). The
prognosis is excellent (>90% 5-year survival).
●● B: The growth extends to the extrarectal tissues, but without
metastasis to the regional lymph nodes (35%). The
prognosis is reasonable (70% 5-year survival).
●● C: There are secondary deposits in the regional lymph
nodes (50%). These are subdivided into C1, in which the
local pararectal lymph nodes alone are involved, and C2,
in which the nodes accompanying the supplying blood
vessels to their origin from the aorta are involved.

28. TNM STAGING
TUMOUR
NODE
METASTASIS

29. T represents the extent of local spread:
●● TX: primary tumour cannot be assessed;
●● T0: no evidence of primary tumour;
●● Tis: carcinoma in situ – intraepithelial or invasion of lamina
propria;
●● T1: tumour invades submucosa;
●● T2: tumour invades muscularis propria;
●● T3: tumour invades through the muscularis propria into
pericolorectal tissues;
●● T4a: tumour penetrates to the surface of the visceral peritoneum;
●● T4b: tumour directly invades or is adherent to other
organs or structures.
more regional

30. N describes nodal involvement:
●● NX: regional lymph nodes cannot be assessed;
●● N0: no regional lymph node metastasis;
●● N1: metastasis in 1–3 regional lymph nodes:
●● N1a: metastasis in 1 regional lymph node
●● N1b: metastasis in 2–3 regional lymph nodes
●● N1c: tumour deposit(s) in the subserosa, mesentery or
nonperitonealised pericolic or perirectal tissues without
regional nodal metastasis;
●● N2: metastasis in 4 or more regional lymph nodes:
●● N2a: metastasis in 4–6 regional lymph nodes
●● N2b: metastasis in 7 or

31. HISTOLOGICAL GRADING
In the great majority of cases, carcinoma of the rectum is an adenocarcinoma, derived from
malignant transformation ofthe columnar rectal epithelium. The more the tumour cells
retain normal shape and arrangement (well-differentiated),the less aggressive the behaviour.
Conversely, the more cells of an undifferentiated type, the more aggressive the behaviour.
Other poor prognostic features include vascular and perineural invasion, the presence of an
infiltrating (rather than pushing)
margin and tumour budding. In a small number of cases, the tumour is a primary mucoid
carcinoma. The mucus lies within the cells, displacing the nucleus to the periphery, like the
seal of a signet ring. Signet-ring carcinomas are rapidly growing, metastasise early and have a
poor prognosis

32. TREATMENT
Surgical excision of the tumour is the conventional management option, provided this can be achieved with
clear oncological margins and acceptable risk of morbidity and mortality. However, the management of rect
cancer has become increasingly complex, because of the various surgical techniques available and the range
neoadjuvant and adjuvant options. As a result, the management of rectal cancer
needs to be within the multidisciplinary team setting, involving surgeons, radiologists, oncologists, pathologi
and specialty nurses. Before treatment can be planned, it is necessary to assess:
●● the fitness of the patient;
●● the extent of spread of the tumour.
Assessment of spread should include CT of the chest,
abdomen and pelvis to exclude distant metastases

33. Assesment Of Spread
MAGNETIC RESONANCE IMAGING SCAN OF THE PELVIS
SHOWING EXTENSIVE T3 RECTAL CANCER INVOLVING THE LEFT
MESORECTUM
COMPUTED TOMOGRAPHY SCAN OF THE ABDOMEN IN A
PATIENT WITH RECTAL CANCER, SHOWING MULTIPLE LIVER
METASTASES

34. Principles of surgical treatment
Radical excision of the rectum, together with the mesorectum
and associated lymph nodes, should be the aim in most cases.
When a tumour appears to be locally advanced (i.e.
invading a neighbouring structure or threatening to breach
the circumferential resection margin), the use of neoadjuvant
(preoperative) radiotherapy or chemoradiotherapy is usually
considered. Long-course chemoradiotherapy is given as 5
fractions of radiotherapy combined with chemotherapy over
a 6-week period. The aim is to down-stage the cancer and
increase the chances of a complete resection with clear oncological
margins.

35. Wait& watch policy
Increasingly, there is a trend for ‘watch-and-wait’ management
in cancers that have shown a complete clinical response
to long-course chemoradiotherapy (about 20%). If there is no
evidence of residual cancer on clinical examination, biopsy or
radiological imaging, patients are offered intense surveillance
in the hope that they may have been cured of the disease
and spared the morbidity of resectional surgery. Some 30% of
cases will recur on a ‘watch-and-wait’ policy

36. surgery
When radical excision is possible, the aim should be to
restore gastrointestinal continuity and continence by preserving
the anal sphincter whenever feasible. A sphincter-saving
operation (anterior resection) is usually possible for tumours
whose lower margin is ≥2 cm above the anorectal junction

37. Surgery for rectal cancer
●● 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 metastases

38. Preoperative preparation
●● Counselling and siting of stomas
●● Correction of anaemia and electrolyte
disturbance
●● Group and save of blood
●● Bowel preparation
●● Deep vein thrombosis prophylaxis
●● Prophylactic antibiotics

39. ANTERIOR RESECTION
Anterior resection: Refers to removal of rectum and
sigmoid colon. Indicated in cases of carcinoma rectum
above peritoneal reflection: It can be low anterior
resection when colorectal anstomosis is done below the
peritoneal reflection or high anterior resection where the
anastomosis is above peritoneal reflection. In this procedure
rectum and sigmoid colon i s removed along with
mesorectum which contain lymphatic channels. Sphincter
function is preserved. Sigmoid colon has to be removed.
Stapler anastomosis is the choice for low
resections. Bowel is clamped and transected just proximal
to this point

41. Abdominal Perineal Resection :
It is also called as Miles-Walker's operation It is indicated
when the growth is too low involving the anal sphincters,
poorly differentiated cancers which are very low. The
patient is put in Lloyd Davis position (supine with
lithotomy). Two surgeons operate simultaneously, one
from the abdomen and one from the perineum. Abdomen
is opened first and the growth is mobilised from the sacrum
and from the urinary bladder.
Pelvic dissection is carriedby abdominal surgeon till levator ani muscles.
At this stage, anus is closed by a purse string by perinea! surgeon.
Rectum and anal canal is mobilized from below. The entire
specimen of rectum with meso rectum and anal canal and
the nodes are removed. It is followed by Permanent EndColostomy
by bringing the sigmoid colon outside in the
left iliac fossa (sphincter sacrificing surgery).

42. STRUCTURES REMOVED IN APR
• Growth with entire rectum and anal canal.
• Fascia propria with pararectal nodes.
• Two-thirds of the sigmoid colon and mesocolon
with
lymphatics and lymph nodes.
• Muscles and peritoneum of pelvic floor.
• Wide area of perianal skin, with part of ischiorectal
fossa

43. APR/ AR

44. More extensive operations
When carcinoma of the rectum has spread to contiguous
organs, the radical operation can often be extended to
remove these structures en bloc. Thus, in the male, in whom
spread is usually to the bladder or prostate, a cystectomy or
prostatectomy may be required in combination with anterior
resection to achieve complete oncological clearance. In the
female, the uterus acts as an oncological barrier, preventing
spread from the rectum to the bladder. Accordingly, a
hysterectomy
can be undertaken in addition to excision of the
rectum. Pelvic evisceration for carcinoma of the rectum is
usually only justifiable when the surgeon is confident that
the cancer can be completely removed with negative
resection
margins.

45. Inoperable cases
Locally advanced growths present with severe pain, bleeding
and with subacute intestinal obstruction. Temporary loop
colostomy is done in the left iliac fossa by bringing the sigmoid
colon outside. Postoperatively, radiation and chemotherapy
are given.
Hartmann's operation
This is indicated in old and
debilitated patients who may not
withstand APR. The rectum is
excised, the lower end of the
rectum is closed and a colostomy
is performed. When the growth is
slow-growing, this operation gives
good palliation.

47. ROLE OF RADIOTHERAPY AND CHEMOTHERAPY
Postoperative Management
1. pT l -2NOMO do not require any adjuvant treatment,
such
patients can be kept on follow-up with routine 3 monthly
CEA and annual CECT thorax/abdomen/pelvis .
2. pT3NOMO or node positive disease requires adjuvant
treatment in the form of concurrent chemoradiotherapy
and
chemotherapy.
Example: 2 cycles of FOLFOX (5-FU + Leucovorin +
Oxaliplatin) 􀁸 concurrent 5-FU/Leucovorin and radiation
􀁸 2 more cycles of FOLFOX.
Oral Capecitabine can be used in place ofIV 5-FU.
3. It is preferable to add Oxaliplatin in the chemotherapy
regimen if nodes were positive for metastatic disease.
Although in older population(> 65-70 years) it might be
of less benefit.