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

Interior of RectumMucous membrane of empty rectum shows two types of foldsLongitudinal fold: - Are transitory.• Present in lower part of empty rectum & obliterated by distension Transverse fold - Permanent• More marked in distended rectumUpper fold – • Near the upper end of rectum & projects from Rt. or Lt. WallMiddle Fold• Largest & most constant lies in upper end of rectal ampulla & projects from

anterior & Rt. WallsLowest Fold• Lies 2.5 cm below middle fold & projects from left wall

Blood SupplyArtery• 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 veinsNerve Supply• Sympathetic from L1, L2• Parasympathetic from S2-S4

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• B1.growth extending into extra rectal tissue but

no lymph nodes spread• B2.invading muscularis mucosa• C.lymph nodes secondaries• D.distant spread to liver, lungs,bones,brain

• TNM-STAGING• Tx—primary not assesssed• T0—no primary tumour• Tis-- carcinoma in situ• T1-- invasion to submucosa• T2-- invasion to muscularis propria• T3-- invasion of subserosa• T4 --involvement of visceral peritoneum• N0-- no nodal spread• N1--1----3 nodal spread• N2-- 4 or more nodal spread• Mo-- no distant spread• M1-- 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 3rd 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 1st and perineum later• Gabriel----perineum 1st 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 4CM SIZE TOMOUR• 5-TI-N0 OR T2-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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