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Amalina Aminuddin Baki082012100067

TUMOURS OF RECTUM

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Most frequent site of polyps in GITMalignancy potential: > 1cm Recommended: removal of all polyps

Give complete histological examination Exclude carcinoma Prevent local recurrence

Done by: Endoscopic hot biopsy Snare polypectomy

If rectal polyp is found on sigmoidoscopy, do colonoscopy Remove rectal polyp only after ruling out proximal

carcinoma

BENIGN TUMORS

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PolypsBenign lymphomaEndometriomaHemangiomaGastrointestinal stromal tumours

BENIGN TUMOURS

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Adenoma: most frequent histological typeVillous adenoma more extensive with tendency to

malignancy than tubular adenomasColonoscopy done to determine presence of other

polyps

Treatment: Colonoscopic polypectomy Transanal/ rectal excision ( large polyps)

1.POLYPS

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JUVENILE POLYPS Infants and children No malignant tendency

unless inherited Bright red glistening

pedunculated sphere = cherry tumour

Large mucus-filled spaces covered by smooth surface of thin rectal cuboidal epithelium

Prolapsed bleeding / pain Removal: spontaneous or

easy removal with forceps/snare

HYPERPLASTIC POLYPS Harmless Multiple, small (2-

4mm), pinkish, sessile polyps

INFLAMMATORY PSEUDOPOLYPS Edematous mucosa

associated with inflammatory diseases (colitis)

1. POLYPS

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VILLOUS ADENOMAS Frond-like appearances Very large Tend to be malignant (RARE) Secrete

potassium-rich mucous electrolyte & fluid loss

Removal: Endoscopic submucosal

resection Per anal surgery Sleeve resection from

above Rectal surgery Transanal endoscopic

microsurgery

TRANSANAL ENDOSCOPIC MICROSURGERY Insert a large operating

sigmoidoscope Rectum distended by

CO2 insufflation Operative field

magnified and displayed on monitor

Lesion excised by specially designed instruments

1.POLYPS

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FAMILIAL ADENOMATOUS POLYPOSISAD – APC ( adenomatous polyposis coli) gene on chr 5

Multiple colon and rectal polyps around puberty

Treatment : Total colectomy with regular

rectal endoscopy and polyps removal

Restorative proctocolectomy with pouch- anus anastomosis

Pan- proctocolectomy with permanent ileostomy

1.POLYPS

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Circumscribed movable nodule Firm, not hard, Greyish-white to pink No definite capsule Submucosal

Rare

Treatment: complete local incision

2.BENIGN LYMPHOMA

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Rare, misdiagnosed as carcinomaCause: ectopic endometrial tissue or tumour from

rectovaginal septum 20 – 40 years old h/o dysmenorrhea and rectal bleeding

Sigmoidoscopy: stricture with intact mucous membrane

Treatment: Hormonal manipulation Total abdominal hysterectomy and bilateral

salpingoophorectomy

3.ENDOMETRIOMA

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Uncommon cause of hemorrhage

Stimulate ulcerative colitis if lesion is diffuse or in upper part of rectum

Treatment: Excision ( at lower

part of rectum) Selective angiography

and embolisation

Rare Treatment:

Radical excision due to uncertainty in behaviour

4. HEMANGIOMA

5. GASTROINTESTINAL STROMAL TUMOUR

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ORIGIN Adenoma accumulation of adenoma-carcinoma sequence (Vogelstein) dysplasia increasing carcinoma

TYPES OF SPREADLocal

Circumferential spread ( 18- 24 m) Penetrate into mesorectum Anterior: prostate, seminal

vesicles, vagina, uterus, bladder Lateral: ureter Posterior: sacrum, sacral plexus

Lymphatic : Upward direction

Venous : liver, lung, adrenals

Peritoneal dissemination: penetration by high-lying rectal carcinoma

CARCINOMA

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1. DUKE’S STAGING

A. Limit to rectal wall, excellent prognosis

B. Extrarectal tissues, reasonable prgnosis

C. Regional LNI. Pararectal LNII. Nodes of

supplying blood vessel

D. Metastasis

STAGING OF CARCINOMA

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Poor prognosis: Vascular invasion Signet cell

2. TNM STAGING

Grade % Prognosis

Low 11 GoodAverage 64 FairHigh 25 Poor

3. HISTOLOGICAL GRADING

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Bleeding Slight amount, at end of defecation or stained underclothes

Tenesmus Spurious diarrhoea with flatus and ‘bloody slime’

Altered bowel habit Increasing constipation : rectosigmoid junction Early morning bloody diarrhoea : ampulla

Pain Colicky : intestinal obstruction Severe pain : Erosion to prostate/ bladder Lower back pain : sacral plexus

CLINICAL FEATURES OF CARCINOMA

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ABDOMINAL EXAMINATION Normal / intestinal

obstruction / ascites

RECTAL EXAMINATION Early : nodule with

indurated base / shallow depression with everted, raised edges

Blood / mucopurulent with blood – stained finger

Oval swellings : involved LN Vaginal examination when

neoplasm at anterior wall

PROCTOSIGMOIDOSCOPY

BIOPSY Portion of edge and

central part

COLONOSCOPY To exclude synchronous

tumor Proximal tumor can be

snared and removed CT colonography or

barium enema

INVESTIGATION

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Inflammatory strictureAmoebic granulomaEndometrioma Carcinoid tumorSolitary ulcer syndrome

DIFFERENTIAL DIAGNOSIS OF CARCINOMA

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Local operationAbdominal operationExtensive operativePalliative operationAdjuvant therapy

TREATMENT

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Small, low grade, mobile (T1) lesion within 10cm of anal verge

Technique: Turnbull York-Mason TEM ( transanal

endoscopic microsurgery)

Combined with chemotherapy and radiotherapy

LOCAL OPERATION

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Before surgery, assess Patient’s fitness Extent of spread of tumor

PET/ endoluminal USG/ CT/ MRI

PRINCIPLES Aim:

Radical excision of rectum, mesorectum Restore GIT continuity and continence

Chemoradiotherapy Preoperative: reduce tumor size to allow curative surgery Post-operative: reduce local recurrence

Patient unfit for radical surgery : local procedure

ABDOMINAL SURGERY

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Mechanical bowel preparation : purgative, enemaCounselling of stomas and complication of procedureCorrection of anaemia and electrolyte imbalancesProphylactic antibiotics : cefuroxime 750mg +

metronidazole 500 mgCatheter insertion

PREOPERATIVE PREPARATION

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Tumors of lower third of rectum that are unsuitable for sphicter- saving procedure

Position : Lloyd- Davies-AllenTwo surgeons :

Sigmoid colon excised Abdominal ( anterior and lateral of rectum

& deepened) Perineal ( close anus, posteriorly around

rectum & deepened) Anus and rectum removed through perineal

wound Colostomy at 2.5cm above spinoumbilical

line

1.COMBINED ( ABDOMINAL & PERINEAL ) EXCISION OF RECTUM

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Rectum mobilised using laparascopePerineum is incisedTransect midsigmoid colon with endoscopic stapler-

cutter instrumentSpecimen delivered through perineal woundEnd-colostomy is done

Reduces post-operative pain and hospital stay but not as curative as open technique

2.LAPAROSCOPIC ABDOMINOPERINEAL EXCISION

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Sphicter-saving operation High (5cm) or low (2cm)

Abdomen incised, rectum mobilised to pelvic floor Excise rectum and sigmoid colon Continuity re-established by double stapling method

(straight /J-shaped) or coloanal anasastomosis via transanal route

Purse- string suture in stump Examine ‘doughnuts’ A stoma is done for safe healing of anastomosis

Irrigation of rectal lumen with 1% cetrimide / TME / neoadjuvant radiotherapy

Available as laparoscopic anterior resection

3.ANTERIOR RESECTION

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Rectum excised through an abdominal incision

Colostomy and closure of anorectal stump

Peritoneum oversewn to cover pelvic defect

Suitable for : Elderly patient Patient with concern

of anal sphicter function or viability of anastomosis

4.HARTMANN’S OPERATION

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Bladder :CystectomyUterus : HysterectomyLiver : liver resection Base of bladder : Pelvic exenteration (Brunschwig’s

operation) Rectus abdominis flap to fill, urinary diversion (ilael conduit)

and colostomy

EXTENSIVE OPERATIONS

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Palliative colostomy Cases causing intestinal obstruction/ infection of neoplasm

Neodymium: yttrium-aluminium-garnet ( Nd:YAG) laser Obstructing / bleeding lesion

Intraluminal stent Obstructing lesion

PALLIATIVE PROCEDURE

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RADIOTHERAPYPalliative : inoperable

primary tumor/ local recurrence

Pre operative: Can be combined with chemotherapy to shrink tumor to surgical size

Post- operative :Reduce local recurrence rate

Intracavity

CHEMOTHERAPYAlso for disseminated

disease treatment5- fluorouracil :

combined with leucovorin

Intraportally during and immediately after operation

New drugs: Irinotecan oxaliplatin

ADJUVANT THERAPY

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SURVIVAL RATEIn specialised centres :

95% resectability <5% operative mortality 50% 5-year survival rate

Lower survival rate in : non-specialised hospital Dukes stage C patient Fixed lesion Low-lying tumour in

rectum Anaplastic lesion

LOCAL RECURRENCE2 - 25 %80% within 2 yearInadequate removal,

implantationPalliative

radiotherapy or resection of involved organ

RESULTS OF RECTAL SURGERY

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Originates in submucosaSmall plaque – like elevation with 10% metastasisSlow progressing, late metastasisTreatment :

Local excision Rectal excision if:

>2.5 cm Recurrence after local excision Fixed to perirectal tissue

CARCINOID TUMOURS

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Bailey and Love’s Short Practice of Surgery; 25 th Edition; Williams, Bulstrode, O’Connell; CRC Press

http://www.amepc.org/tgc/article/view/1134/1454http://www.netterimages.com

REFERANCE