RECTAL PROLAPSE

Rectal Prolapse: 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.

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.

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 prolapse Complete prolapse

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

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?

Examining for rectal prolapse

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

Radiologic examination

 Irreducibility (table sugar!) Complications of rectal prolapse:  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

TREATMENT Prolapse 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

Prolapsed in Adult Partial prolapse:  Injections of 5% phenol in oil in submucosa. 10-15ml total.  Electrical stimulation with sphincteric exercises.

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)

Rectal cancer

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 bronchus 31% Prostate 10% Colon and rectum 10% Pancreas 5% Leukemia 4% Esophagus 4% Liver and intrahepatic 3% bile duct Non-Hodgkin 3% Lymphoma Urinary bladder 3% Kidney 3% All other sites 24%

Decreasing mortality of CRC 5-year Survival 1960-70 1980-90 Colon cancer 40-45% 60% Rectal cancer 35-40% 58%

Anatomic Location of CRC Cecum 14 % Ascending colon 10 % Transverse colon 12 % Descending colon 7 % Sigmoid colon 25 % Rectosigmoid junct.9 % Rectum 23 % 70%

Epidemiology Increasing Incidence of CRC Incidence 30-40 / 100000 / year >70 y. of age 300 / 100000 / year third most common malignant disease second most common cause of cancer death

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

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

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

Anal Cancer Anal cancer

Middle rectal cancer

Symptoms !!! RECTAL EXAMINATION 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

Investigations Staging: - Recto- and colonoscopy - Barium enema - CT - MRI - EUS

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

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.

MRI – standard of care

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

Clinical Staging of CRC Astler-Coller modified Dukes stage TNM Primary Lymph-node Distant Dukes stage tumor metastasis metastasis stage Stage 0 Tis N0 M0 A A Stage I T1 N0 M0 A A1 T2 N0 M0 A B1 Stage II T3 N0 M0 B B2 T4 N0 M0 B B2 Stage III A any T N1 M0 C C1/C2 B any T N2, N3 M0 C C1/C2 Stage IV any T any N M1 D D

TNM Classification Extension Tis T1 T2 T3 T4 Mucosa Muscularis mucosae to an adjacent organ Mucosa Muscularis mucosae Submucosa Muscularis propria Subserosa Serosa

Stage and Prognosis Stage 5-year Survival (%) 0,1 Tis,T1;No;Mo > 90 I T2;No;Mo 80-85 II T3-4;No;Mo 70-75 III T2;N1-3;Mo 70-75 III T3;N1-3;Mo 50-65 III T4;N1-2;Mo 25-45 IV M1 <3

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

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

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

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

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

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)

Type of surgery

INVOLVEMENT OF MESORECTAL FASCIA

Abdomino-perineal resection MILES

Anterior resection and very low anterior resection

Follow up!!

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

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

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

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

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

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