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RECTAL CARCINOMA
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Rectum• The rectum is about 12 cm long & upper part breath 4 cm • Present in pelvic cavity
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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
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External ApperanceThe rectum can be distinguished by• absence of mesentery & appendices epiploicae• absence of sacculations• teniae coli to form longitudinal muscle coat
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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
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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
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Venous Drainage• follow arteries• however free anastomosis exist between
the superior, middle & inferior rectal veinsNerve Supply• Sympathetic from L1, L2• Parasympathetic from S2-S4
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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
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PATHOLOGY
#HISTOLOGICALLY• Adenocarcinoma#GROSS• Ulcerative• Papilliferous• Infilterative• Annular
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Gross specimen of resected rectal ca
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Well differentiated adenocarcinoma
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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
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• VENOUS SPREAD• Liver 35%, lungs 20%, adrenas 10%• PERINEURAL SPREAD
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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
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• 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
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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
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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
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• 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
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• 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
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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
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• 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
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• 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
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• 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
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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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THANK YOU