this is a complete guide to the understanding of the anatomy clinical features and the latest investigation to the most modern methods of treating the case of carcinoma rectum , all the latest journal published and the ongoing trials hav been searched and incorporated
2. WHY IS RECTAL CARCINOMA DIFFERENT
• ANATOMY
• RELATIONS
• MESORECTUM
• LATERAL NODAL SPREAD .
3. INTRODUCTION
• 41,000 NEW DIAGNOSES OF RECTAL CANCER EACH YEAR*
• 10,000 DEATHS ATTRIBUTABLE TO THIS DISEASE
• ADENOCARCINOMA MAKES 30% OF THESE CANCERS.
• HISTORY OF RECTAL CANCER RESECTION DATES BACK TO 1884
• CZÉRNY DESCRIBED THE FIRST ABDOMINOPERINEAL RESECTION (APR).
• IN 1908, MILES “ZONE OF UPWARD SPREAD.” **
*Jemal A et al. Cancer statistics, 2003. CA Cancer J Clin. 2003;53:5.
**Miles WE. Cancer. 1908;2:1812. Abdominoperineal Excision: Evolution of a Centenary Operation
4.
5. WILLIAM HEALD
• PROFESSOR WILLIAM HEALD
• TOTAL MESORECTAL EXCISION (TME) IN 1980
• REDUCED LOCAL SPREAD FROM 50% TO 3.6 %
Heald, RJ; et al. (1982). "The mesorectum in rectal cancer surgery-the clue to pelvic recurrence?". Br J Surg (John
Wiley & Sons, New Jersey) 69: 613–616.
Heald RJ, Moran BJ, Ryall RD, et al. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–
6. MESORECTUM
• MESENTRY SURROUNDING THE RECTUM
• COVERED BY THE VISCERAL LAYER OF THE ENDOPELVIC FASCIA
• CONTAINS
PERIRECTAL FAT
DRAINING LYMPH NODES
SUPERIOR RECTAL BLOOD VESSELS
• HOLY PLANE – LOOSE AREOLAR TISSUE SEPARATING THE VISCERAL AND
PARIETAL LAYERS
• PARIETAL LAYER COVERS THE SUPERIOR HYPOGASTRIC PLEXUS
,HYPOGASTRIC PLEXUS AND PELVIC PLEXUS.Reference: Heald, RJ; et al. (1982). "The mesorectum in rectal cancer surgery-the clue to pelvic
recurrence?". Br J Surg (John Wiley & Sons, New Jersey) 69: 613–616.
8. ANATOMY
• 15CM
• STARTS - 3RD SACRAL VERTEBRA
• ENDS 2-3CM INFRONT OF THE COCCYX
• THE RECTUM IS “FIXED” POSTERIORLY AND LATERALLY BY WALDEYER’S
FASCIA
• ANTERIORLY : DENONVILLIERS’ FASCIAReference: NCCN guidelines on colorectal carcinoma,
Fishers mastery of surgery 6th edition,Maingots abdominal operations 12th edition
9. Arterial supply
Superior rectal artery
Middle rectal artery
Inferior rectal artery
Sato K, Sato T. The vascular and neuronal composition of the lateral ligament of the rectum and the rectosacral fascia.
Surg Radiol Anat. 1991;13:17–22.
10. Venous supply
Superior rectal vein
Middle rectal vein
Inferior rectal vein
Reference:Sato K, Sato T. The vascular and neuronal composition of the lateral ligament of the rectum and the
rectosacral fascia. Surg Radiol Anat. 1991;13:17–22.
11. NERVE SUPPLY
• SYMPATHETIC , L1–L3
• SACRAL (PARASYMPATHETIC), S2-S4
• INFERIOR HYPOGASTRIC NERVES
INNERVATE - RECTUM, BLADDER, URETER, PROSTATE, SEMINAL VESICLES,
MEMBRANOUS URETHRA, CORPORA CAVERNOSA.
• INJURY- IMPOTENCE, BLADDER DYSFUNCTION, AND LOSS OF NORMAL DEFECATORY
MECHANISMS.
Reference: Sato K, Sato T. The vascular and neuronal composition of the lateral ligament of the rectum and the
rectosacral fascia. Surg Radiol Anat. 1991;13:17–22.
12. Reference: Sato K, Sato T. The vascular and neuronal composition of the lateral ligament of the rectum and the
rectosacral fascia. Surg Radiol Anat. 1991;13:17–22.
14. ETIOLOGY AND RISK FACTORS
• LIFETIME RISK FOR AN INDIVIDUAL TO DEVELOP COLORECTAL CANCER IS
APPROXIMATELY 6%.
• INFLAMMATORY BOWEL DISEASE
• GENETIC CAUSES (MISMATCH REPAIR GENES MSH2 AND MLH1)
• AFP (FAMILIAL ADENOMATOUS POLYPOSIS)
• DIETARY HABITS
Maingot’s abdominal operations 12th edition
Wei EK, Giovannucci E, Wu K, et al. Comparison of risk factors for colon and rectal cancer. Int J Cancer.
2004;108:433–442. 5. Martínez ME, McPherson RS, Annegers JF, Levin B. Cigarette smoking and alcohol
consumption as risk factors for colorectal adenomatous polyps. J Natl Cancer Inst. 1995;87:274–279.
15. SYMPTOMATOLOGY
• BOWEL HABITS OR STOOL CALIBER, RECTAL PAIN, A SENSE OF RECTAL “FULLNESS,” WEIGHT
LOSS, NAUSEA, VOMITING, FATIGUE, OR ANOREXIA
• TENESMUS USUALLY IS INDICATIVE OF A LARGE AND POSSIBLY FIXED STAGE II OR III
CANCER.
• PAIN WITH DEFECATION SUGGESTS INVOLVEMENT OF THE ANAL SPHINCTERS.
Reference: Ueno H, Yamauchi C, Hase K, et al. Clinicopathological study of intrapelvic cancer spread to the iliac
area in lower rectal adenocarcinoma by serial sectioning. Br J Surg. 1999;86:1532–1537.
16. INVESTIGATIONS
• CT SCAN
• TRANSRECTAL ENDOLUMINAL OR ENDOSCOPIC ULTRASOUND (TRUS)
• MRI
Orrom WJ, Wong WD, Rothenberger DA, et al. Endorectal ultrasound in the preoperative staging of rectal tumors: a
learning experience. Dis Colon Rectum. 1990;33:654–659.
Garcia-Aguilar J, Pollack J, Lee SK, et al. Accuracy of endorectal ultrasonography in preoperative staging of rectal
tumors. Dis Colon Rectum. 2002;45:10–15.
17. INVESTIGATIONS
• BIPAT ET AL ANALYSIS
• EUS
• 3D EUS FOR T1 AND T2 STAGE TUMORS
• FOR NODAL STAGING USING ULTRASMALL SUPERMAGNETIC PARTICLES OF IRON OXIDE
• MRI
• DW-MRI T3 ,T4 TUMORS
• HIGH RESOLUTION MRI FOR CRM
• GANDOLIUM ENHANCED MRI FOR LOCAL RECURRENCE (RIM ENHANCEMENT DIFFERENCIATES
FROM POSTOPERATIVE FIBROSIS )
• NOTE: BOTH FAIL TO DISTINGUISH T2,T3 DUE TO THE PRESENCE OF DESMOPLASTIC REACTION
AROUND TUMOR
Reference: bipat S,Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM,StockerJ.RECTAL CANCER : local staging and
assesment of lymph node involvementwith endoluminal US,CT,and MR Imaging – a meta
18.
19.
20.
21.
22. TREATMENT
• AIMS
• RELIVE SYMPTOMS AND PROLONG SURVIVAL
• PREVENT OR MINIMISE THE LOCOREGIONAL RECURRENCE AND DISTANT
METASTASIS
• PRESERVE URINARY AND SEXUAL FUNCTION
• PRESERVE SPHINCTER FUNCTION WHENEVER POSSIBLE
24. EUROPEAN ORGANIZATION FOR RESEARCH
AND TREATMENT OF CANCER TRIAL
• 1011 PATIENST IN 4 GROUPS LOCAL
RECURRENCE AT 5 YR
1. PRE-OP RT FOLLOWED BY SURGERY 17%
2. PRE-OP CTRT (5FU + LV) FOLLOWED BY SURGERY
8.7%
3. PRE-OP RT FOLLOWED BY SURGERY + POST-OP CT (5-FU + LV)
9.6%
4. PRE-OP CTRT FOLLOWED BY SURGERY + POST-OP CT
7.6%
• RESULTS
Reference : Bardet E, et al .EORTC radiotherapy trial group 22921. chemotherapy with preoperative radiotherapy in
rectal cancers .N Engl J Med 2006;355(11):1114-23
25. SURGICAL PROCEDURES
• SPINCTER SAVING
• ANTERIOR RESECTION
• LOW ANTERIOR RESECTION
• INTERSPINCTERIC RESECTION
• LOCAL EXCISION
• SPINCTER COMPROMISE
• ABDOMINOPERINIAL RESECTION
Reference: Roshan lall gupta’s recent advances in surgery : Management of rectal cancer : current status
26. CHOICE OF OPERATION
• PATIENT FACTORS
• TUMOR LOCATION
• TUMOR STAGE
Reference: Roshan lall gupta’s recent advances in surgery : Management of rectal cancer : current status
27. RESECTION MARGINS
• INTRAMURAL EXCISION
• 2 CM OF THE DISTAL MARGIN INTRAMURAL MARGIN
• 5 CM OF THE PROXIMAL MARGIN INTRAMURAL MARGIN
• MESORECTAL EXCISION
• UPPER RECTAL GROWTH – 5CM
• MID AND LOWER RECTUM – TOTAL MESORECTUM
Reference : Jemal A,Tiwari RC,murray T,et al . Cancer statistics2004.CA Cancer J Clin2004;54;8-29
Agarwal A,et al. Total mesorectal excision : In:GI Surg Annual ,ed T K Chattopadhyay 2001;(8):57-69.
Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst.
28. WHAT IS CIRCUMFERENTIAL RADIAL MARGIN
• CIRCUMFERENTIAL RADIAL MARGIN (CRM) IS AN INDEPENDENT
PREDICTOR OF BOTH LOCAL RECURRENCE AND SURVIVAL.
• SIGNIFICANCE OF CRM POSITIVE STATUS .
• SIGNIFICANCE OF CRM NEGATIVE STATUS .
CRM LR RATE P VALUE
> 2mm 3.3% <0.0001
1to 2mm 8.5% 0.02
< 1mm 13.1% 0.08
Reference: Roshan lall gupta’s recent advances in surgery : Management of rectal cancer : current
29. LOCAL EXCISION
• T1N0 OR T2N0 LESION <4 CM IN DIAMETER
• <40% CIRCUMFERENCE OF THE LUMEN
• <10 CM FROM DENTATE LINE WELL TO MODERATELY DIFFERENTIATED HISTOLOGY
• NO EVIDENCE OF LYMPHATIC OR VASCULAR INVASION ON BIOPSY
References: Maingot’s abdominal operations 12th edition , Rectum and anal canal
30. APPROACH
• TRANSANAL (<3CM FROM THE DENTATE LINE)
• TRANSCOCCYGEAL (<5CM FROM THE DENTATE LINE)
• TRANSANAL ENDOSCOPIC MICROSURGERY
(7-10CM FROM THE DENTATE LINE)
Garcia-Aguilar J, Shi Q, Thomas CR Jr, et al. A phase II Trial of Neoadjuvant Chemoradiation and Local Excision for
T2N0 Rectal Cancer: preliminary results of the ACOSOG Z6041 trial. ANN Surg Oncol. 2012;19:384–391.
Transanal
Transcoccygeal
31. LOW ANTERIOR RESECTION WITH TOTAL
MESORECTAL EXCISION
• TME ALONG WITH LAR OR APR INVOLVES PRECISE DISSECTION AND REMOVAL
OF THE ENTIRE RECTAL MESENTERY.
• AUTONOMIC NERVE PRESERVATION (ANP) .
32. TECHNIQUE OF TOTAL MESORECTAL
EXCISION
• MODIFIED LITHOTOMY POSITION
• A LOW MIDLINE INCISION
• THE SIGMOID IS MOBILIZED LATERALLY BY SCORING THE WHITE LINE OF TOLDT
• TRANSVERSE COLON IS FREED FROM THE OMENTUM BY SHARP DISSECTION ALONG THE
AVASCULAR PLANE BETWEEN THE TWO STRUCTURES.
• THE BOWEL IS PACKED INTO THE UPPER ABDOMEN.
33. • THE COLON IS DIVIDED AT THE SIGMOID-DESCENDING COLON JUNCTION
• THE SUPERIOR HEMORRHOIDAL ARTERY IS THEN DIVIDED AT THE JUNCTION
WITH THE LEFT COLIC ARTERY
• THE RECTUM IS RETRACTED ANTERIORLY THE DISSECTION IS CARRIED
INFERIORLY TO THE COCCYX.
• ANTERIOR AND LATERAL RECTAL DISSECTION
• IT IS IMPORTANT TO KEEP THE DISSECTION OF THE MESORECTUM
PERPENDICULAR TO THE SITE OF TRANSECTION.
• “CONING IN” AS ONE DIVIDES THE MESORECTUM PRIOR TO TRANSECTION
SHOULD BE AVOIDED.
• RECONSTRUCTION: DOUBLE-STAPLING
38. ABDOMINOPERINEAL RESECTION
• THIS PROCEDURE INVOLVES THE EN BLOC RESECTION OF THE TUMOR AS
WELL AS THE SURROUNDING LYMPH NODES AND THE ANAL SPHINCTERS,
RESULTING IN A PERMANENT COLOSTOMY.
• 5-YEAR SURVIVAL RATES FOLLOWING AN APR RANGE FROM
• 78 TO 100% FOR STAGE I,
• 45 TO 73% FOR STAGE II,
• 22 TO 66% FOR STAGE III DISEASE
Enker WE, Havenga K, Polyak T, et al. Abdominoperineal resection via total mesorectal excision and
autonomic nerve preservation for low rectal cancer. World J Surg. 1997;21:715–720. 52.
West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P. Evidence of the oncologic superiority of
cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol. 2008;26(21):3517–3522. [Epub 2008
39. PERINEAL DISSECTION
• THE DISSECTION PROCEEDS DOWN TO THE STRIATED MUSCLES OF THE LEVATOR ANI
• THE ANUS IS CLOSED WITH A NO. 0 SILK SUTURE IN A PURSE-STRING FASHION .
• DRAW AN ELLIPSE 2 CM ,PERINEAL BODY ANTERIORLY, COCCYX POSTERIORLY, AND
ISCHIAL TUBEROSITIES LATERALLY.
• THE DISSECTION IS DEEPENED OUTSIDE THE EXTERNAL SPHINCTER TOWARD THE
TIP OF THE COCCYX
• . THE ANOCOCCYGEAL LIGAMENT IS PALPATED JUST ANTERIOR TO THE TIP OF
COCCYX AND BREECHED
• HOOKING THE INDEX AND MIDDLE FINGERS UNDER THE LEVATOR MUSCLES AND
TRANSECTING WITH ELECTROCAUTERY FREES THE RECTUM LATERALLY
• THE ANTERIOR SURFACE IS DISSECTED LAST
40. LATERAL NODAL DISSECTION
• LATERAL NODAL SPREAD, ESPECIALLY IN DISTAL RECTAL CANCERS, IS ONE
POSSIBLE CULPRIT FOR TREATMENT FAILURES IN RECTAL CANCER
• TME WITH RADIOTHERAPY AND LATERAL NODAL DISSECTION WITHOUT
RADIOTHERAPY RESULT IN EXCELLENT LOCAL CONTROL AND HAVE IMPROVED
LOCAL CONTROL OVER TME ALONE.
41. ANALYSIS
COMPARATIVE STUDY OF JAPANESE AND DUTCH PATIENTS
DUTCH PATIENTS JAPANESE PATIENTS
TME TME+RT TME+LATERAL PELVIC
DISSECTION
• LOCAL RECURRENCE 12.1 5.8 6.9
• LATERAL PELVIC RECURRENCE 2.7 0.8 2.2
• PRESACRAL RECURRENCE 3.2 3.7 0.6
Reference: Kusters M, Beets GL, van de Velde CJ, et al. A comparison between the treatment of low rectal cancer
in Japan and the Netherlands, focusing on the patterns of local recurrence. Ann Surg. 2009;249(2):229–235. 46.
Akasu T, Sugihara K, Moriya Y. Male urinary and sexual functions after mesorectal excision alone or in combination
with extended lateral pelvic lymph node dissection for rectal cancer. Ann Surg Oncol. 2009;16(10):2779–2786.
42. EXTRALEVATOR TECHNIQUE IN
ABDOMINOPERINIAL RESEARCH
• ABDOMINAL DISSECTION STOPS AT LEVATORS
• PERINIAL DISSECTION TAKES IN EXTRALEVATOR PLANE ,CUTTING THE
LEVATORS AT THE ATTACHMENT TO THE PELVIC SIDE WALLS .
Nagtegaal ID Dutch colorectal cancer group ; Pathology review committee.low rectal cancer:a
call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23(36):9257-
64.
Quirke P et al . Trial investigators ; NCRI colorectal cancer study group . Effect of plane of
surgery achieved on local recurrence in patients with operable rectal cancer .
44. Graciloplasty for the Rectovaginal Fistula after Chemoradiation
Followed by Total Mesorectal Excision for Rectal Cancer
Narimantas Evaldas Samalavicius MD1 , Rakesh Kumar Gupta
MS•2
RESEARCH
45.
46. EN BLOC EXCISION WITH RECTUM
• POSTERIOR VAGINECTOMY
• PROSTATECTOMY
• PROPHYLACTIC BILATERAL OOPHORECTOMY
48. TRIALS
• OPEN V/S LAPROSCOPIC V/S ROBOTIC
• CLASSIC TRIALS AND COREAN TRIAL FOUND NO DIFFERENCE BETWEEN OPEN AND
LAPROSCOPIC IN TERMS OF SURVIVAL, NODAL YIELD, MARGIN POSITIVITY
• HOWEVER ADVANTAGES BETTER VISION , SHORTER STAY, REDUCED ANALGESIC NEED
• BOTH A POSITIVE CRM AND WORSE SEXUAL FUNCTION ARE MAJOR POTENTIAL
COMPLICATION
• ROBOTIC BETTER THAN LAPROSCOPIC IN TERMS OF ERGONOMICS , DEEP PELVIC
DISSECTION
• STUDY BY BAIK ET AL SHOWED CONVERTION RATE LESS IN CASE OF ROBOTIC
• ROLARR TRIAL HAS BEGAN AND IN PROCESS ……
49. CAN WE AVOID SURGERY AFTER COMPLETE
RESPONSE TO CTRT
• STUDY IN BRAZIL HAS SHOWN SIMILAR SYSTEMIC RECURRENCE AND OVERALL
SURVIVAL
• BUT, THE PATIENTS KEPT ON CONSERVATIVE MANAGEMENT WERE SEEN TO
HAVE LOCAL RECURRENCE LIMITED TO RECTAL WALL .
Habr – gama A,prez RO et al .patterns of failure and survival for nonoperative treatment of stage C0 distal
rectal cancer following neoadjuvant chemoradiation therapy . J gastrointest Surg 2006;10:1319-28
50. ADVANCES IN LOCALLY RECURRENT RECTAL
CANCER
• PELVIC RECURRENCES AS CLASSIFIED BY LEEDS GROUP
1. CENTRAL ONLY PELVIC ORGANS NO BONY INVOLVEMENT)
2. SIDE WALL
3. SACRAL
4. COMPOSITE (BOTH SACRAL AND SIDE WALL)
55. • INTERNATIONAL JOURNAL OF SURGERY JOURNAL( WWW.THEIJS.COM)
• INTUSSUSCEPTION IN ADULTS: INSTITUTIONAL REVIEW
• RAKESH KR. GUPTA A, *, CHANDRA SHEKHAR AGRAWAL A , ROHIT YADAV A , AMIR BAJRACHARYA A ,
PANNA LAL SAH B
• AGASTROINTESTINAL (GI) UNIT, DEPARTMENT OF SURGERY, B.P. KOIRALA INSTITUTE OF HEALTH SCIENCES, DHARAN, NEPAL
BDEPARTMENT OF RADIOLOGY, B.P. KOIRALA INSTITUTE OF HEALTH SCIENCES, DHARAN, NEPAL.
• CONCLUSIONS: CT SCANNING PROVED TO BE THE MOST USEFUL DIAGNOSTIC RADIOLOGIC
METHOD. COLONOSCOPY IS MOST ACCURATE IN ILEOCOLIC AND COLONIC AI.
• THE TREATMENT OF ADULT INTUSSUSCEPTION IS SURGICAL.
• REVIEW SUPPORTS THAT SMALL-BOWEL INTUSSUSCEPTION SHOULD BE REDUCED BEFORE
RESECTION IF THE UNDERLYING ETIOLOGY IS SUSPECTED TO BE BENIGN OR IF THE RESECTION
REQUIRED WITHOUT REDUCTION IS DEEMED TO BE MASSIVE.
• LARGE BOWEL SHOULD GENERALLY BE RESECTED WITHOUT REDUCTION BECAUSE PATHOLOGY
IS MOSTLY MALIGNANT.
56. Rectosigmoid Endometriosis Causing an Acute Large Bowel Obstruction: A
Report of a Case and a Review of the Literature Gupta
RK1 ,Agrawal CS1 , Yadav RP1 ,Uprety D2 , Sah PL 3 1 Department of Surgery, 2
Department of Obstetrics and Gynecology, 3Department of Radiology, B.P. Koirala Institute of Health Sciences,
Dharan, Nepal.
Reporting a successfully-treated case of a 30-year-old woman in which endometrial
infiltration of the large bowel caused acute obstruction, requiring emergency surgery to
relieve the symptom and confirm the diagnosis.
