RECTAL CARCINOMA Rectum The rectum is about 12

RECTAL CARCINOMA

Rectum • The rectum is about 12 cm long & upper part breath 4 cm • Present in pelvic cavity

Position & Extent • begins opposite Sacral Vertebra 3 as continuation of sigmoid colon • passes downwards, following curve of sacrum & coccyx • Then extends downwards forward about 2 -3 cm in front & below tip of coccyx • It abruptly turns downwards & backwards & is continuous with anal canal at anorectal junction

External Apperance The rectum can be distinguished by • absence of mesentery & appendices epiploicae • absence of sacculations • teniae coli to form longitudinal muscle coat

Interior of Rectum Mucous membrane of empty rectum shows two types of folds Longitudinal fold: - Are transitory. • Present in lower part of empty rectum & obliterated by distension Transverse fold - Permanent • More marked in distended rectum Upper fold – • Near the upper end of rectum & projects from Rt. or Lt. Wall Middle Fold • Largest & most constant lies in upper end of rectal ampulla & projects from anterior & Rt. Walls Lowest Fold • Lies 2. 5 cm below middle fold & projects from left wall

Blood Supply Artery • sup rectal art - Continuation of Inferior mesenteric artery • middle rectal art - Branch of Internal Iliac Artery • median sacral art - Branch of Abdominal Aorta

Venous Drainage • follow arteries • however free anastomosis exist between the superior, middle & inferior rectal veins Nerve Supply • Sympathetic from L 1, L 2 • Parasympathetic from S 2 -S 4

AETIOLOGY Red meat and saturated fatty acids Alcohol and smoking Familial adenomatous polyp IBD HNPCC(heridatory Non Polyposis Colorectal Cancer) • Family history of rectal carcinoma • • •

PATHOLOGY #HISTOLOGICALLY • Adenocarcinoma #GROSS • Ulcerative • Papilliferous • Infilterative • Annular

Gross specimen of resected rectal ca

Well differentiated adenocarcinoma

SPREAD • Local spread • Initially circumferentially and later spreads out to muscular coat and peri-rectal tissue. • Then to prostate, bladder, seminal vesicles in males and ureters and vagina in female. • Posteriorly into sacrum and sacral plexus. • LYMPHATIC SPREAD • Along the colonic lymph nodes • In mid-rectum----rectal and mid-rectal nodes

• VENOUS SPREAD • Liver 35%, lungs 20%, adrenas 10% • PERINEURAL SPREAD

STAGING • MODIFIED DUKE’S STAGING • A. growth limited to rectal wall • B 1. growth extending into extra rectal tissue but no lymph nodes spread • B 2. invading muscularis mucosa • C. lymph nodes secondaries • D. distant spread to liver, lungs, bones, brain

• • • • TNM-STAGING Tx—primary not assesssed T 0—no primary tumour Tis-- carcinoma in situ T 1 -- invasion to submucosa T 2 -- invasion to muscularis propria T 3 -- invasion of subserosa T 4 --involvement of visceral peritoneum N 0 -- no nodal spread N 1 --1 ----3 nodal spread N 2 -- 4 or more nodal spread Mo-- no distant spread M 1 -- distant spread present

CLINICAL FEATURES • • • Bleeding per rectum------earliest symptom Spurious diarrhea Tenesmus Sense of incomplete evacuation May present as piles -------due to proximal venous congestion Altered bowel habit Anemia & malnutrition Urinary symptoms due to bladder infiltration Ascites and liver secondaries

INVESTIGATIONS • 1)ABDOMINAL EXAMINATION • Normal in early cases • Advanced annular tumour at rectosigmoid junction-----signs of int. obstruction. • Palpable liver----metastasis • Ascites ---secondary deposits to peritoneum

• 2)PER RECTAL EXAMINATION • DRE---nodule with an indurated base • Bimanual examination---may be possible to feel the lower extremity of a carcinoma situated in rectosigmoid junction • Carcinoma in lower 3 rd of rectum------lymph nodes 1 or more hard, oval swellings in the mesorectum posteriorly or posterolaterally above the tumour • In females----vaginal examination is must

• 3)PROCTOSIGMOIDOSCOPY • Will always show carcinoma----rectum should be empty before hand • 4)BIOPSY • Using biopsy forceps via a sigmoidoscope---will confirm the diagnosis • 5)COLONOSCOPY • To exclude other tumours. • 6)ultrasound

MANAGEMENT • • A) PRE-OPERATIVE PREPARATION Mechanical bowel preparation Counselling and siting of stomas Correction of anaemia and electrolye disturbances Cross-matching of blood Prophylactic antibiotics DVT prophylaxis Insertion of urethral catheter

• B)SURGERY • 1)Abdomino-perineal resection(APR-OPERATION) • Sigmoid, descending colon and upper rectum is mobilised per-abdominally • Anal canal with perianal and perirectal tissue are dissected per anally • Retained colon is brought out as end colostomy in LIF. • 3 TYPES------ • MILES---abdomen 1 st and perineum later • Gabriel----perineum 1 st and abdomen later • Lioyd-davis----combined

• 2)ANTERIOR RESECTION. • Done in growths located in the mid and upper part of rectum. • CRITERIA • 1 -UPPER AND MIDDLE THIRD RECTAL GROWTH • 2 -ABOVE PERITONEAL REFLECTION • 3 -WELL-DIFFERENTIATED TUMOUR • 4 -LESS THAN 4 CM SIZE TOMOUR • 5 -TI-N 0 OR T 2 -NO TUMOUR

• 3)HARTMANN’S OPERATION • PALLIATIVE PROCEDURE DONE IN ELDERLY • Rectal growth is resected and upper end of rectum is closed completely • Proximal colon is brought out as end colostomy. • 4)PELVIC EVISCERATION • 5)PALLIATIVE COLOSTOMY

C)RADIOTHERAPY -useful when growth is below the level of peritoneal reflection D)CHEMOTHERAPY -5 -FU, folinic acid etc E)LASER PHOTOCOAGULATION

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