2 Rectal Prolapse: Prolapse of the rectum mainly two types: Partial or incomplete prolapse (procidentia) when the mucousmembrane lining the anal canal protrudes throughthe anus only. Complete prolapse in which the whole thickness ofthe bowel protudes through the anus.Rectal prolapse occurs most often at extremesof life e.g, in children between 1-5 years of age and elderly people. More common in female than male.
3 Aetiology the predisposing causes are:- Straining at stool. In children:the predisposing causes are:- The vertical straight course of the rectum. Reduction of supporting fat in the ischiorectal fossa. Straining at stool. Chronic cough.
4 Partial prolapse Complete prolapse In adult: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.Partial prolapseComplete prolapse
5 Clinical Features 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 restAsk patient to bear down – most still not evidentNeed 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?
10 Irreducibility (table sugar!) Complications of rectal prolapse: Irreducibility (table sugar!) Infection Ulceration Severe haemorrhage fromone of the mucosal vein Thrombosis and obstruction of the venous returns leading to oedema Irreducibility and gangrene
11 TREATMENTProlapse in children: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.ANORECTAL DISORDERS
12 Prolapsed in AdultPartial prolapse: Injections of 5% phenol in oil in submucosa ml total. Electrical stimulation with sphincteric exercises.
13 Surgery always necessary, none are ideal. Complete prolapse:Surgery always necessary, none are ideal. Thiersch’s operation Rectopexy Rectosigmoidectomy Ivalon sponge rectopexy Ripstein operation Low anterior resection (minor)
15 2005 Estimated US Cancer Deaths* 15% Breast10% Colon and rectum6% Ovary6% Pancreas4% Leukemia3% Non-Hodgkin lymphoma3% Uterine corpus2% Multiple myeloma2% Brain/ONS22% All other sites27% Lung and bronchusLung and bronchus 31%Prostate 10%Colon and rectum 10%Pancreas 5%Leukemia 4%Esophagus 4%Liver and intrahepatic 3% bile ductNon-Hodgkin % LymphomaUrinary bladder 3%Kidney 3%All other sites %
16 Decreasing mortality of CRC 5-year SurvivalColon cancer % 60%Rectal cancer % 58%
29 Tumor markersCEACA 19-9Dynamic may be significant for recurrence
30 Clinical Staging of CRC Astler-CollermodifiedDukes stageTNM Primary Lymph-node Distant Dukesstage tumor metastasis metastasis stageStage 0 Tis N0 M0 A AStage I T1 N0 M0 A A1T2 N0 M0 A B1Stage II T3 N0 M0 B B2T4 N0 M0 B B2Stage IIIA any T N1 M0 C C1/C2B any T N2, N3 M0 C C1/C2Stage IV any T any N M1 D D
31 TNM Classification Extension Tis T1 T2 T3 T4 Mucosa Muscularis mucosae to an adjacentorganMucosaMuscularis mucosaeSubmucosaMuscularis propriaSubserosaSerosa
32 Stage and Prognosis Stage 5-year Survival (%) 0,1 Tis,T1;No;Mo > 90 I T2;No;MoII T3-4;No;MoIII T2;N1-3;MoIII T3;N1-3;MoIII T4;N1-2;MoIV M1 <3
33 Purpose of Radio(chemo)therapy in Rectal Cancer To lower local failure rates and improve survival in resectable cancersto allow surgery in primarly inextirpable cancersto facilitate a sphincter-preserving procedureto 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 commonLocal 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 failurePostoperative RT (35+Gy): 33% relative reduction
36 ESMO Recommendations Resectable cases Surgical procedure: TMEPreoperative RT: recommendedPostoperative chemoradiotherapy: T3,4 or N+Non-resectable cases: local recurrencesPreoperative 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 anastomoticleakage-Tumor perforationTumor-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)therapy2. Importance of circumferential margin (TME)
42 Epidermoid carcinoma 75% of all malignancies of the area Early: verucous, nodular lesionLate: ulcerated, indurated, nodular nmassPalpable inguinal nodesMay invade the rectum: false impression of rectal carcinomaLymphatic 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 anus50% pigmentedLymph node MTS earlyTreatment - not clear advantage of any alternative
45 Bowen’s disease: Squamous cell carcinoma in situ Like all other places of skinPlaque-like eczematoid lesion + pruritusBiopsy-carcioma in situ + hyperkeratosis and giant cellsTherapy: local excision with safety margins
46 Basal cell carcinoma Ulcerating tumor (uncommon) “Rodent ulcer” like every other place of skin exposedDoesn’t spread distantlyLocal 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 appendagesLocal excision (without mass)Radical surgery + chemo + RT for coloid carcinoma