RECTAL CARCINOMA
Rectum
• The rectum is about 12 cm long & upper part breath 4 cm
• Present in pelvic cavity
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
External Apperance
The rectum can be distinguished by
• absence of mesentery & appendices epiploicae
• absence of sacculations
• teniae coli to form longitudinal muscle coat
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
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
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
AETIOLOGY
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Red meat and saturated fatty acids
Alcohol and smoking
Familial adenomatous polyp
IBD
HNPCC(heridatory Non Polyposis Colorectal
Cancer)
• Family history of rectal carcinoma
PATHOLOGY
#HISTOLOGICALLY
• Adenocarcinoma
#GROSS
• Ulcerative
• Papilliferous
• Infilterative
• Annular
Gross specimen of resected rectal ca
Well differentiated adenocarcinoma
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
• VENOUS SPREAD
• Liver 35%, lungs 20%, adrenas 10%
• PERINEURAL SPREAD
STAGING
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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
CLINICAL FEATURES
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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
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
• 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
• 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
MANAGEMENT
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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
• 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
• 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
• 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
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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