CASE PRESENTATION April 2017 Prepared By: Dr. Shadi A. Abumeteir Resident General Surgery R4 Dr. Mohamed El-Dahdouh Resident General Surgery R1 Supervised by: Dr. Mohamed Al Ron Consultant of General Surgery April 2017

Introduction The association between ulcerative colitis and colorectal cancer was first reported in the 1920s, it has been confirmed in many studies from different countries. The overall prevalence of CRC in any UC patient, based on 116 studies, was estimated to be 3.7% (95% CI 3.2-4.2%). These incidence rates corresponded to cumulative probabilities of 2% by 10 years, 8% by 20 years, and 18% by 30 years.

Case Report : A Case of Laparoscopic Total Proctocolectomy for Ulcerative Colitis with Rectal Cancer

Personal history Name: M. SH. Age: 65 years old Sex: Male Address: Gaza Occupation: Unemployed Marital Status: Married Special Habits: Non Smoker Date of Admission: 05/03/2017

Known case of Ulcerative colitis for 20 years. History of illness Known case of Ulcerative colitis for 20 years. Multiple hospital admissions due to exacerbation of the disease “abdominal pain, bleeding per rectum and tenesmus” 6 months ago he was diagnosed as a case of rectal cancer.

Past History Patient was on regular Corticosteroid and immunosuppressors. No history of chronic medical illness (D.M,HTN,IHD,…) No H/O previous surgeries nor blood transfusion. Family History Family history of IBD. His father died with history of rectal cancer. Systemic review Not significant.

/ NORMAL General examination Cachectic. BMI was 19.5 kg/m2 On examanition General examination Cachectic. BMI was 19.5 kg/m2 Vitally stable Abdomen exam Chest exam Heart exam Back and scrotum / NORMAL

Clinical Examination cont. PR Palpable circumferential, hard, fungating mass at 3 cm from the anal verge. Loose bloody stool, Fibrotic sphincter. No external abnormalities

Investigations B A C D E Investigations Routine lab. tests Radiology Abdominal Ultrasound CT Scan colonoscopy

Lab Investigation Routine lab. tests: CRP: 30.7 mg/dl CBC: Hb 11.4 gm/dl, WBC 6.1X10³/ml, PLT 485. Blood group: A +ve. Serum Chemistry: FBS 87mg/dl, urea 38 mg/dl, creat 0.96 mg/dl, ALT 12 u/L, AST 19u/L, Alk ph 175 u/L, Amy 48 u/L. Alb 2.4 g/dl Electrolytes: Na 146 mEq/l K 4.3 mEq/l Ca 9.65mg/dl Coagulation profile: PT: 14.9 Activity 84% INR 1.07 CRP: 30.7 mg/dl

Imaging CXR: AXR: Radiology: Normal bony skeleton and lung aireation ,no mediastinal masses. AXR: Plain X-ray showed dilatation of the transverse colon reaching diameters of 5.0 cm. Abdominal Ultrasound: No Free Fluid No Localized collection No intra-abdominal masses, enlarged L.Ns nor ascites.

17/11/2016 Colonoscopy :

24/11/2016 Biopsy Result :

19/11/2016 CT Scan:

Case was discussed in the MDT meeting Neoadjuvant chemo-radiotherapy followed by CT follow up

05-03-2017 Post Chemoradiation CT :

After 6 weeks, the case was discussed again in the MDT

The date of surgery was in 06.03.2017 Summary 65 years male pt was admitted to the surgical ward as a case of ulcerative colitis with rectal tumor for laparoscopic proctocolectomy with permeant ileostomy. Surgery was planned The date of surgery was in 06.03.2017

Operative details Laparoscopic proctocolectomy is likely one of the most challenging laparoscopic procedures for the colon and rectal surgeon as it involves operating in multiple quadrants of the abdomen as well as performing pelvic dissection.

elderly, patients with poor anal continence, and Operative details Proctocolectomy and permanent ileostomy is an option for selected patients with ulcerative colitis. Current indications include the elderly, patients with poor anal continence, and those with malignant lesions of the low rectum.

Advantages of this procedure are Operative details Advantages of this procedure are it has fewer complications than an ileal pouch-anal anastomosis, it is a one-stage operation removing all the diseased mucosa, it is a relatively straightforward operation.

The major disadvantage that patients are Operative details The major disadvantage that patients are permanent incontinent stoma requiring the constant wearing of an external appliance, possible perineal wound complications such as delayed healing; acute and chronic stoma complications; physiologic consequences such as electrolyte abnormalities; urinary and gallstone formation; complications associated with pelvic dissection such as urinary and sexual dysfunction.

Pre-, intra-,post-operative care according to ERAS

Post op care Post operatively , recovery was smooth , without any complications , drain was removed after 3 days , patient discharged after 5 days . Patient was followed up 2 weeks later in the OPC , patients was in good general condition, wound was clean , ileostomy functioning well .

Thank You ! End