Rectal cancer rapid review

1. Rectal cancer
Pre-operative evaluation of patients with rectal cancer
Some trials in Rectal cancer
• MERCURY study
• Sauer et al NEJM
• Van Gijn W et al
• Stockholm III study
• MOSAIC study
• ADORE study

2. Introduction and features
• MC site of CRC is rectum
• Adenocarcinoma
• Multiple in 5%
• Presents as a rectal ulcer MC
polypoidal
• Metastasis  Liver, Lungs, Adrenal
• Clinical features [History]
• 55 years
• Bleeding PR
• Sense of incomplete evacuation of
stool
• Tenesmus
• Spurious diarrhea with bloody slime
• Alteration in bowel habit
• (Annular carcinoma patients at
rectosigmoid junction Obstruction
(Constipation)
• Back pain/ sciatica  Invasion into
sacral plexus

3. Physical examination
• Rectal cancers have higher risk of local
recurrence
• Because of difference in blood supply/
location the cancer of rectum are special
and deserve special attention
• Upper rectum Liver
• Lower rectum Lungs
• On physical examination if rectal mass in
palpable
• DRE
• Good anal sphincter tone present/not
• If present Think about sphincter sparing
operation.
• Document Anterior, Posterior, Left or
Right
• In women Rectovaginal septum
involvement should be identified
• Proctoscopy
• Tumor height
• [never do with endoscope]
• Staging
• EUS (Trans rectal ultra sonography)
• T-staging can be accurately done
• 3 white lines and 2 hypoechoic lines
• MRI
• Rectal cancer protocol
• MRI accessed in the same axis as the rectum
• Pelvic MRI LN involvement status,
circumferential resection margin status, extra
rectal disease
• Clinically T3 and node positive rectal
cancers and cancers with close
proximity of sphincter Pre-
operative neoadjuvant
chemoradiation.

7. A page where
MRI-rectum can
be learned
https://radiopaedia.org/cases/83562
/studies/98669?lang=us

8. • 1980 Richard Herald popularized “complete excision of mesorectum”
• Remove entire mesorectum intact using sharp dissection
• German rectal cancer study (2004)
• Pre-operative chemoradiation patients  lower rate of local recurrence, sphincter-
sparing procedures and both acute and long-term toxicity were seen with pre-
operative treatment.
• No difference in morbidity and mortality of patients
• Quirke and colleagues Pre-operative chemo radio with TME recognized
that combination treatment leads to improved outcomes in rectal cancer
surgery
• Professor Habr Gama Concept of “watch and wait”

15. Local excision
Endoscopic technique
• Routine polypectomy
• Endoscopic mucosal resection
• Endoscopic submucosal resection
• Trans anal Micro Surgery (TAMIS)
• Trans anal endoscopic
microsurgery
• Usually villous adenomas of lower
rectum are amenable to
endoscopic excision
Trans anal technique
• Small lesions (<2 cm)
• Well-differentiated cancers within
the reach of index finger
• Mobile lesions
• Usually for lateral and posterior
lesions (not necessary that
anterior are not done, risk of
injury to anterior structures is
more)

16. Resections for rectal cancer
• Parts of rectum:
• Proximal rectum (15-10 cm from anal
verge)
• Mid rectum (10-5 cm from anal verge)
• Distal rectum (5cm or less)
• Mid rectum and distal rectum are
extraperitoneal
• Resection types
• Lower anterior resection
• Sphincter sparing procedures
• Transanal TME
• Abdominoperineal resection
• Why is TME challenging?
• Rectum anatomy within narrow
pelvis
• Close anatomic relation with
genitourinary organs and endopelvic
nerves
• Radical resection must be performed
along a very precise anatomic plane
en bloc with mesorectum
• Need to preserve meso rectal fascia
during resection ( to prevent local
recurrence )
• [Surgical management]

18. LAR with total/ subtotal TME
• Subtotal ME above 1/3rd tumor
• Total ME Distal 2/3rd tumor

19. Sphincter sparing procedure for low rectal
cancer
• In young and fit patients with
good preoperative sphincter
function and with no infiltration
of sphincter by tumor
sphincter sparing procedure can
be done.
• Dissection and resection is
performed transanally
• Steps:
• Sphincter denudation starting
distal to the tumor with scissors or
harmonic scalpel
• Standard mucosectomy is used
• Distal mucosa peeled off from
internal sphincter up to 1-2 cm
above dentate line. This causes
sparing of internal sphincter.
• If portion of the sphincter is used 
asymmetrical mucosectomy
• Note that 3 varieties of sphincter
saving resections exist

20. Sphincter sparing procedure– Variation 1

21. Sphincter sparing procedure– Variation 2

22. Sphincter sparing procedure– Variation 3

23. Abdominoperineal resection(Miles procedure)
• Tumors infiltrating the sphincter
 complete excision of both anus
and rectum is done along with
sphincter apparatus
• End colostomy is made
• Usually option for elderly patients
with distal rectal cancer with poor
sphincter function because end-
colostomy offers better quality of
life compared with ultra distal
coloanal anastomosis
• 2 operations
• Abdominal and perineal part
• Perineal part of operation is begun
after the creation of colostomy
aperture.
• Perineal defect created during the
surgery can be closed using rectus
abdominis or gracilis flap
• Specimen Origin of IMA+
Mesorectum with hemorrhoidal
vessels+ ultra distal rectum+ anal
sphincter

24. Synchronous cancers
• Depending upon site the
resections are indicated
• Left and right synchronous
cancers abdominal colectomy
with IRA is done
• If cancers are in rectum Total
proctocolectomy with IPAA
• When tension free anastomosis is not
achieved in patients undergoing re-
resection surgery following
techniques are adopted
• Retroileal transmesenteric route
• Counter clock rotation of the right
colon to reach the pelvis f/b
colorectal anastomosis [Deloyers
procedure]
Short residual colon

25. Retro-ileal trans mesenteric route