1. RECTAL PROLAPSE

2. 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.

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 prolapse
Complete 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 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?

7. Examining for rectal prolapse

8. 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

9. Radiologic examination

10.  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

11. 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

12. Prolapsed in Adult
Partial 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)

14. Rectal cancer

15. 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 % Lymphoma
Urinary bladder 3%
Kidney 3%
All other sites %

16. Decreasing mortality of CRC
5-year Survival
Colon cancer % 60%
Rectal cancer % 58%

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

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

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

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

22. 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

23. Anal Cancer
Anal cancer

24. Middle rectal cancer

25. 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

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

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

28. 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.

29. MRI – standard of care

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

31. 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

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

33. Stage and Prognosis Stage 5-year Survival (%) 0,1 Tis,T1;No;Mo > 90
I T2;No;Mo
II T3-4;No;Mo
III T2;N1-3;Mo
III T3;N1-3;Mo
III T4;N1-2;Mo
IV M1 <3

34. 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

35. 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

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

37. 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

38. 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

39. 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)

40. Type of surgery

41. INVOLVEMENT OF MESORECTAL FASCIA

42. Abdomino-perineal resection MILES

43. Anterior resection and very low anterior resection

44. Follow up!!

45. 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

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

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

48. 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

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

50. 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