REctal Carcinoma Diagnosis and Treatment

By Dr Yar Jahan

1. CARCINOMA RECTUM CPC Surgical Unit 1

2. Age greater than 50

3. Spread Local ( Anteriorly it can spread to Prostate, seminal vesicle or bladder in males. Vagina and uterus in females. Posterioly sacrum or sacral plexus. Lateraly ureter .) Hematogenous spread ( liver, lungs, adrenals, brain) Lymphatic spread (upper rectum, superior rectal vessels to inferior mesenteric LN, in inferior rectum inferior rectal vessels to internal iliac LN.) Peritoneal dissemination

4. Investigations General investigation (CBC, RFT, LFT, serum electrolyte, viral marker, chest X-ray, ECG) Fecal occult blood test Sigmoidoscopy Colonoscopy + Biopsy (for accurate diagnosis , for synchrous tumor) CT Scan Abdomen with IV contrast ( diagnosis,staging & extent of the tumor) CT virtual colonoscopy CT chest (for metastatic workup and staging of disease) MRI Pelvis (to see extent of tumor in soft tissues, superior to CT in lower third of rectum) Double contrast barium enema ( applecore . Irregular filling deposit) Endoscopic ultrasound (for staging, local extension) PET scan (for metastatic workup) CEA level (for diagnosis and more for prognostic workup)

5. Anterior Resection For upper and middle one third Above peritoneal reflections Well differentiated Less than 4cm T1, T2 No lymphatic spread Advantages (sphincter saving) Disadvantages (increased chances of recurrence, increased chances of leakage and infection)

6. TYPES OF ANTERIOR RESECTION

7. Types of Anterior Resection High anterior resection (for distal sigmoid and recto-sigmoid tumor and final anastmosis was above peritoneal reflection, above and below 5mm margin clearance) Low anterior resection (for upper rectal tumor and final anastmosis below peritoneal reflection Ultralow anterior resection (for mid and low rectal tumor, above margin 5mm, below margin 2mm)

8. Total M esorectal Excision Sharp dissection along the anatomic plane to ensure complete resection of rectal mesentery during low and ultra low anterior resection. Advantages (it increases local recurrence rate and improve long term survival. Less risk of damage to pelvic nerve)

9. Abdomino Perineal Excision of the Rectum Through open or Laproscopic APR Indication Lower third of the rectum Lymph node involved Mesorectum involved Poorly differentiated carcinoma Candidates who are unfit for sphincter saving operations Advantages (it gives adequate clearance and decreases chances of recurrence) Disadvantages (need stoma care so less acceptable by the patient)

10. Pelvic E xenteration Indication When there is involvement of another pelvic organ or tumor recurrence Rectal and perineal operations are similar to APR but enbloc resection of ureter , bladder, prostate, uterus, vagina, sacrum is performed

11. Liver resection Single or multiple well localised mets in liver can be resected at the time of surgery or delay.

12. Palliative Surgery Endoluminous stenting Palliative colostomy

13. Radiotherapy Adjuvant and neo adjuvant radiotherapy for cancer

14. 3 to 5 year After every 3 month for 2 year d) Endorectal ultrasound, every 4 month for 3 year, then every 6 month for 2 year e) CT Scan AP.