1. RECTAL CARCINOMA

2. Rectum
The rectum is about 12 cm long & upper part breath 4 cm
Present in pelvic cavity

3. 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

4. External Apperance
The rectum can be distinguished by
absence of mesentery & appendices epiploicae
absence of sacculations
teniae coli to form longitudinal muscle coat

5. Interior of Rectum
Mucous membrane of empty rectum shows two types of folds
Longitudinal fold: - Are transitory.
Present in lower part of empty rectum & obliterated by distension
 Transverse fold - Permanent
More marked in distended rectum
Upper fold –
Near the upper end of rectum & projects from Rt. or Lt. Wall
Middle Fold
Largest & most constant lies in upper end of rectal ampulla & projects from anterior & Rt. Walls
Lowest Fold
Lies 2.5 cm below middle fold & projects from left wall

7. Blood Supply
Artery
sup rectal art - Continuation of Inferior mesenteric artery
middle rectal art - Branch of Internal Iliac Artery
median sacral art - Branch of Abdominal Aorta

8. Venous Drainage
follow arteries
however free anastomosis exist between the superior, middle & inferior rectal veins
Nerve Supply
Sympathetic from L1, L2
Parasympathetic from S2-S4

10. 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

11. PATHOLOGY #HISTOLOGICALLY Adenocarcinoma #GROSS Ulcerative
Papilliferous
Infilterative
Annular

12. Gross specimen of resected rectal ca

13. Well differentiated adenocarcinoma

14. 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

15. VENOUS SPREAD
Liver 35%, lungs 20%, adrenas 10%
PERINEURAL SPREAD

16. 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

17. 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
N nodal spread
N or more nodal spread
Mo-- no distant spread
M1-- distant spread present

19. 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

20. 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

21. 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

23. 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

27. 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

28. 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

29. 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

30. 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

31. C)RADIOTHERAPY -useful when growth is below the level of peritoneal reflection D)CHEMOTHERAPY -5-FU, folinic acid etc E)LASER PHOTOCOAGULATION

33. THANK YOU