RECTAL PROLAPSE Rectal Prolapse Prolapse of the rectum

RECTAL PROLAPSE

Rectal Prolapse: Prolapse of the rectum mainly two types: Partial or incomplete prolapse (procidentia) when the mucous membrane lining the anal canal protrudes through the anus only. Complete prolapse in which the whole thickness of the bowel protudes through the anus. Rectal prolapse occurs most often at extremes of life e. g, in children between 1 -5 years of age and elderly people. More

In children: Aetiology the predisposing causes are: - The vertical straight course of the rectum. Reduction of supporting fat in the ischiorectal fossa. Straining at stool. Chronic cough.

In adult: the predisposing causes depend on type of the prolapse. Partial prolapse Advance degree of prolapsing piles. Loss of sphincteric tone. Straining from urethral obstruction. Operations for fistula. Complete prolapse is generally regarded as sliding hernia of the recto vesical or recto vaginal pouch due to stretching of the levator from pregnancy, obesity.

Prolapse is first noted during defaecation. Discomfort during defaecation. Bleeding. Mucous discharge. Bowel habit irregular and may lead to incontinence.

Examining for rectal prolapse w Most NOT evident in lying position as rest w Ask patient to bear down – most still not evident w Need to examine after straining on the toilet for 1 -2 minutes – lean forward – observe from behind – estimate in centimetres - ? full thickness circumferential, or partial mucosal only?

Examining for rectal prolapse

Ano-rectal digital examination w Resting tone (low = IAS problem) w Squeeze pressure (low = EAS problem) w Co-ordination w Sensation (? Neurological dysfunction) w Assessment stops here for MOST patients

Radiologic examination

Complications of rectal prolapse: Irreducibility (table sugar!) Infection Ulceration Severe haemorrhage from one of the mucosal vein Thrombosis and obstruction of the venous returns leading to oedema Irreducibility and gangrene

the prolapse tends to disappear spontaneously by the age of 5 years. So conservative measures are sufficient. Prolapse in children: Conservative treatment: constipation and straining at stool are avoided and the buttocks may be strapped together to discourage prolapse during defaecation. Perirectal injection of alcohol/phenol may be used to fix the lax mucosa to underlying tissue.

Partial prolapse: Injections of 5% phenol in oil in submucosa. 10 -15 ml total. Electrical stimulation with sphincteric exercises.

Complete prolapse: Surgery always necessary, none are ideal. Thiersch’s operation Rectopexy Rectosigmoidectomy Ivalon sponge rectopexy Ripstein operation Low anterior resection (minor)

Rectal cancer

2005 Estimated US Cancer Deaths* Lung and bronchus 31% w 15% Breast Prostate 10% w 10% Colon and rectum 10% w 6% Ovary Pancreas 5% w 6% Pancreas Leukemia 4% Esophagus 4% w 4% Leukemia Liver and intrahepatic 3% bile duct Non-Hodgkin Lymphoma 3% w 3% Uterine corpus w 2% Multiple myeloma Urinary bladder 3% Kidney 3% All other sites w 3% Non-Hodgkin lymphoma 24% w 2% Brain/ONS w 22% All other sites w 27% Lung and bronchus

Decreasing mortality of CRC 5 -year Survival 1960 -70 1980 -90 Colon cancer 40 -45% 60% Rectal cancer 35 -40% 58%

Anatomic Location of CRC w Cecum 14 % w Ascending colon 10 % w Transverse colon 12 % w Descending colon 7 % w Sigmoid colon 25 % w Rectosigmoid junct. 9 % w Rectum 23 % 70%

Epidemiology w Increasing Incidence of CRC w Incidence 30 -40 / 100000 / year w >70 y. of age 300 / 100000 / year w third most common malignant disease w second most common cause of cancer death

Epidemiology w 70% of CRC are resectable at diagnosis w Mortality has decreased

Ethiology w Diet: fibers, vit E, vit C w Polips (adenomatous) w IBD – more then 10 years of progression w Smoking w Cyclooxigenase inhibitors w Genetic cancer

WHO Classification of CRC w w w w w Adenocarcinoma in situ / severe dysplasia Adenocarcinoma Mucinous (colloid) adenocarcinoma (>50% mucinous) Signet ring cell carcinoma (>50% signet ring cells) Squamous cell (epidermoid) carcinoma Adenosquamous carcinoma Small-cell (oat cell) carcinoma Medullary carcinoma Undifferentiated Carcinoma

Symptoms Bleeding per anum Sensation of incomplete bladder empting Tenesmus Abdominal pain Palpable rectal tumor w Pacienţi în stadii avansate: pierdere ponderală, hepatomegalie, icter, anemie. w Examenul fizic include: aprecierea stării generale, a prezenţei adenopatiilor periferice şi a hepatomegaliei. !!! RECTAL EXAMINATION

Investigations w Staging: - Recto- and colonoscopy - Barium enema - CT - MRI - EUS

w RECTOSCOPY w COLONOSCOPY + BIOPSY Indications - Suggestive images on barium enema - Suggestive symptoms of colonic cancer - Screening -After polipectomy

COMPUTER-TOMOGRAFIA (aspecte CR)

EUS Accuracy 81 -93% More difficult to interpret Limited value in evaluation of LN invasion Requires contact with tumor and a lumen in which to be inserted.

MRI – standard of care

Tumor markers w CEA w CA 19 -9 – Dynamic may be significant for recurrence

Clinical Staging of CRC TNM stage Primary tumor Lymph-node metastasis Distant metastasis Dukes stage Astler-Coller modified Dukes stage Stage 0 Tis N 0 M 0 A A Stage I T 1 N 0 M 0 A A 1 T 2 N 0 M 0 A B 1 T 3 N 0 M 0 B B 2 T 4 N 0 M 0 B B 2 A any T N 1 M 0 C C 1/C 2 B any T N 2, N 3 M 0 C C 1/C 2 Stage IV any T any N M 1 D D Stage III

TNM Classification Tis T 1 T 2 T 3 T 4 Mucosa Muscularis mucosae Submucosa Muscularis propria Subserosa Serosa Extension to an adjacent organ

Stage and Prognosis Stage 5 -year Survival (%) 0, 1 Tis, T 1; No; Mo > 90 I II T 2; No; Mo 80 -85 70 -75 III T 2; N 1 -3; Mo III IV T 4; N 1 -2; Mo T 3 -4; No; Mo T 3; N 1 -3; Mo M 1 70 -75 50 -65 25 -45 <3

Purpose of Radio(chemo)therapy in Rectal Cancer w To lower local failure rates and improve survival in resectable cancers w to allow surgery in primarly inextirpable cancers w to facilitate a sphincter-preserving procedure w to cure patients without surgery: very small cancer or very high surgical risk

Rectal Cancer w Surgery is the mainstay of treatment of RC w After surgical resection, local failure is common w Local recurrence after conventional surgery: – 15%-45% (average of 28%) w Radiotherapy significantly reduces the number of local recurrences

Radiotherapy in the management of RC – Preoperative RT (30+Gy): 57% relative reduction of local failure – Postoperative RT (35+Gy): 33% relative reduction

ESMO Recommendations w Resectable cases – Surgical procedure: TME – Preoperative RT: recommended – Postoperative chemoradiotherapy: T 3, 4 or N+ w Non-resectable cases: local recurrences – Preoperative RT with or without CT

Predicting risk of recurrence in RC w Surgery-related w Tumor-related -Low anterior resection -Anatomic location -Excision of the mesorectum -Histologic type -Extent of lymphadenectomy -Tumor grade -postoperative anastomotic -Pathologic stage leakage -Tumor perforation -radial resection margin -neural, venous, lymphatic invasion

Total Mesorectal Excision (TME) w Local recurrence rates after surgical resection of RC have decreased from about 30% to < 10% – 1. Radio(chemo)therapy – 2. Importance of circumferential margin (TME)

Abdomino-perineal resection MILES

Anterior resection and very low anterior resection

Follow up!!

Epidermoid carcinoma w 75% of all malignancies of the area – Early: verucous, nodular lesion – Late: ulcerated, indurated, nodular nmass w Palpable inguinal nodes w May invade the rectum: false impression of rectal carcinoma w Lymphatic spread: like rectal + inguinal nodes

Treatment w External radiation + concomitant chemotherapy w Radical surgery in case of failure

Malignant melanoma w Horrible prognosis w Dark mass protruding from the anus w 50% pigmented w Lymph node MTS early w Treatment - not clear advantage of any alternative

Bowen’s disease: Squamous cell carcinoma in situ w Like all other places of skin w Plaque-like eczematoid lesion + pruritus w Biopsy-carcioma in situ + hyperkeratosis and giant cells w Therapy: local excision with safety margins

Basal cell carcinoma w Ulcerating tumor (uncommon) w “Rodent ulcer” like every other place of skin exposed w Doesn’t spread distantly w Local excision

Paget’s disease w Rare condition w Pale plaquelike condition with induration + nodular mass (not always) w Nodular mass= coloid carcinoma from glands or other skin appendages w Local excision (without mass) w Radical surgery + chemo + RT for coloid carcinoma