Presentation is loading. Please wait.

Presentation is loading. Please wait.

RECTAL PROLAPSE. Prolapse of the rectum mainly two types:  Partial or incomplete prolapse (procidentia) when the mucous membrane lining the anal canal.

Similar presentations


Presentation on theme: "RECTAL PROLAPSE. Prolapse of the rectum mainly two types:  Partial or incomplete prolapse (procidentia) when the mucous membrane lining the anal canal."— Presentation transcript:

1 RECTAL PROLAPSE

2 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 common in female than male. 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 common in female than male. Rectal Prolapse:

3 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. 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 children:

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

5  Prolapse is first noted during defaecation.  Discomfort during defaecation.  Bleeding.  Mucous discharge.  Bowel habit irregular and may lead to incontinence.  Prolapse is first noted during defaecation.  Discomfort during defaecation.  Bleeding.  Mucous discharge.  Bowel habit irregular and may lead to incontinence.

6 Examining for rectal prolapse  Most NOT evident in lying position as rest  Ask patient to bear down – most still not evident  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?

7 Examining for rectal prolapse

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

9 Radiologic examination

10  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  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 Complications of rectal prolapse:

11 the prolapse tends to disappear spontaneously by the age of 5 years. So conservative measures are sufficient.  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. the prolapse tends to disappear spontaneously by the age of 5 years. So conservative measures are sufficient.  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. Prolapse in children:

12 Partial prolapse:  Injections of 5% phenol in oil in submucosa ml total.  Electrical stimulation with sphincteric exercises.  Injections of 5% phenol in oil in submucosa ml total.  Electrical stimulation with sphincteric exercises.

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

14 Rectal cancer

15 2005 Estimated US Cancer Deaths*  15%Breast  10%Colon and rectum  6%Ovary  6%Pancreas  4%Leukemia  3%Non-Hodgkin lymphoma  3%Uterine corpus  2%Multiple myeloma  2%Brain/ONS  22% All other sites  27%Lung and bronchus Lung and bronchus31% Prostate10% Colon and rectum10% Pancreas5% Leukemia4% Esophagus4% Liver and intrahepatic3% bile duct Non-Hodgkin 3% Lymphoma Urinary bladder3% Kidney3% All other sites 24%

16 Decreasing mortality of CRC 5-year Survival Colon cancer40-45% 60% Rectal cancer35-40% 58%

17

18 Anatomic Location of CRC  Cecum14 %  Ascending colon10 %  Transverse colon12 %  Descending colon7 %  Sigmoid colon25 %  Rectosigmoid junct.9 %  Rectum23 % 70%

19 Epidemiology  Increasing Incidence of CRC  Incidence / / year  >70 y. of age 300 / / year  third most common malignant disease  second most common cause of cancer death

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

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

22 WHO Classification of CRC  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

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

24 InvestigationsInvestigations  Staging: - Recto- and colonoscopy - Recto- and colonoscopy - Barium enema - CT - CT - MRI - EUS - EUS  Staging: - Recto- and colonoscopy - Recto- and colonoscopy - Barium enema - CT - CT - MRI - EUS - EUS

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

26 COMPUTER-TOMOGRAFIA (aspecte CR)

27 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.

28 MRI – standard of care

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

30 TNM Primary Lymph-node DistantDukes stage tumor metastasis metastasisstage Stage 0TisN0M0AA Stage IT1N0M0AA1 T2N0M0AB1 Stage IIT3N0M0BB2 T4N0M0BB2 Stage III Aany TN1M0CC1/C2 Bany TN2, N3M0CC1/C2 Stage IVany Tany NM1DD Astler-Coller modified Dukes stage Clinical Staging of CRC

31 TisT 1 T 2 T 3 T 4 Extension to an adjacent organ Mucosa Muscularis mucosae Submucosa Muscularis propria SubserosaSerosa TNM Classification

32 Stage and Prognosis Stage5-year Survival (%) 0,1 Tis,T1;No;Mo > 90 I T2;No;Mo II T3-4;No;Mo III T2;N1-3;Mo III T3;N1-3;Mo III T4;N1-2;Mo IV M1 <3

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

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

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

36 ESMO Recommendations  Resectable cases – Surgical procedure: TME – Preoperative RT: recommended – Postoperative chemoradiotherapy: T3,4 or N+  Non-resectable cases: local recurrences – Preoperative RT with or without CT

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

38 Total Mesorectal Excision (TME)  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)

39 Abdomino-perineal resection MILES

40 Anterior resection and very low anterior resection

41 Follow up!!

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

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

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

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

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

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


Download ppt "RECTAL PROLAPSE. Prolapse of the rectum mainly two types:  Partial or incomplete prolapse (procidentia) when the mucous membrane lining the anal canal."

Similar presentations


Ads by Google