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.Rectal Prolapse:

Aetiologythe predisposing causes are:-

The vertical straight course of the rectum. Reduction of supporting fat in the ischiorectal fossa. Straining at stool. Chronic cough. In children:

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. In adult: Partial prolapseComplete prolapse

Prolapse is first noted during defaecation.

Discomfort during defaecation.

Bleeding.

Mucous discharge.

Bowel habit irregular and may lead to incontinence.

Examining for rectal prolapseMost NOT evident in lying position as restAsk patient to bear down most still not evidentNeed 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 examinationResting tone (low = IAS problem)Squeeze pressure (low = EAS problem)Co-ordinationSensation (? Neurological dysfunction)Assessment stops here for MOST patients

Radiologic examination

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 gangreneComplications of rectal prolapse:

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.Prolapse in children:

Injections of 5% phenol in oil in submucosa. 10-15ml total.

Electrical stimulation with sphincteric exercises.

Partial prolapse:

Surgery always necessary, none are ideal.

Thierschs operation Rectopexy Rectosigmoidectomy Ivalon sponge rectopexy Ripstein operation Low anterior resection (minor)

Complete prolapse:

Rectal cancer

2005 Estimated US Cancer Deaths*15%Breast10%Colon and rectum 6%Ovary 6%Pancreas 4%Leukemia 3%Non-Hodgkin lymphoma 3%Uterine corpus 2%Multiple myeloma 2%Brain/ONS22% All other sites27%Lung and bronchusLung and bronchus31%Prostate10%Colon and rectum10%Pancreas5%Leukemia4%Esophagus4%Liver and intrahepatic3% bile ductNon-Hodgkin 3% Lymphoma Urinary bladder3%Kidney3%All other sites 24%

Decreasing mortality of CRC5-year Survival1960-701980-90

Colon cancer40-45% 60%

Rectal cancer35-40% 58%

Anatomic Location of CRC

Cecum14 %Ascending colon10 %Transverse colon12 %Descending colon7 %Sigmoid colon25 %Rectosigmoid junct.9 %Rectum23 %70%

EpidemiologyIncreasing Incidence of CRCIncidence 30-40 / 100000 / year>70 y. of age 300 / 100000 / yearthird most common malignant diseasesecond most common cause of cancer death

Epidemiology70% of CRC are resectable at diagnosisMortality has decreased

EthiologyDiet: fibers, vit E, vit CPolips (adenomatous)IBD more then 10 years of progressionSmokingCyclooxigenase inhibitorsGenetic cancer

WHO Classification of CRCAdenocarcinoma in situ / severe dysplasiaAdenocarcinomaMucinous (colloid) adenocarcinoma (>50% mucinous)Signet ring cell carcinoma (>50% signet ring cells)Squamous cell (epidermoid) carcinomaAdenosquamous carcinomaSmall-cell (oat cell) carcinomaMedullary carcinomaUndifferentiated Carcinoma

Bleeding per anumSensation of incomplete bladder emptingTenesmusAbdominal painPalpable rectal tumorPacieni n stadii avansate: pierdere ponderal, hepatomegalie, icter, anemie.Examenul fizic include: aprecierea strii generale, a prezenei adenopatiilor periferice i a hepatomegaliei.!!! RECTAL EXAMINATIONSymptoms

Investigations

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

RECTOSCOPYCOLONOSCOPY + BIOPSY

Indications

- Suggestive images on barium enema- Suggestive symptoms of colonic cancer- Screening-After polipectomy

COMPUTER-TOMOGRAFIA (aspecte CR)

EUS Accuracy 81-93% More difficult to interpretLimited value in evaluation of LN invasionRequires contact with tumor and a lumen in which to be inserted.

MRI standard of care

Tumor markersCEACA 19-9Dynamic may be significant for recurrence

TNM Primary Lymph-node DistantDukesstage tumor metastasis metastasisstage

Stage 0TisN0M0AAStage IT1N0M0AA1T2N0M0AB1Stage IIT3N0M0BB2T4N0M0BB2Stage IIIAany TN1M0CC1/C2Bany TN2, N3M0CC1/C2Stage IVany Tany NM1DD

Astler-CollermodifiedDukes stageClinical Staging of CRC

TisT1T2T3 T4

Extensionto an adjacentorganMucosaMuscularis mucosae

Submucosa

Muscularis propria

SubserosaSerosaTNM Classification

Stage and PrognosisStage5-year Survival (%)0,1Tis,T1;No;Mo> 90IT2;No;Mo80-85IIT3-4;No;Mo70-75IIIT2;N1-3;Mo70-75IIIT3;N1-3;Mo50-65IIIT4;N1-2;Mo25-45IVM1

Purpose of Radio(chemo)therapy in Rectal CancerTo lower local failure rates and improve survival in resectable cancersto allow surgery in primarly inextirpable cancersto facilitate a sphincter-preserving procedureto cure patients without surgery: very small cancer or very high surgical risk

Rectal CancerSurgery is the mainstay of treatment of RCAfter surgical resection, local failure is commonLocal 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 failurePostoperative RT (35+Gy): 33% relative reduction

ESMO RecommendationsResectable casesSurgical procedure: TMEPreoperative RT: recommendedPostoperative chemoradiotherapy: T3,4 or N+

Non-resectable cases: local recurrencesPreoperative RT with or without CT

Predicting risk of recurrence in RCSurgery-related-Low anterior resection-Excision of the mesorectum-Extent of lymphadenectomy-postoperative anastomoticleakage-Tumor perforationTumor-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)therapy2. Importance of circumferential margin (TME)

Abdomino-perineal resectionMILES

Anterior resection and very low anterior resection

Follow up!!

Epidermoid carcinoma75% of all malignancies of the areaEarly: verucous, nodular lesionLate: ulcerated, indurated, nodular nmassPalpable inguinal nodesMay invade the rectum: false impression of rectal carcinomaLymphatic spread: like rectal + inguinal nodes

TreatmentExternal radiation + concomitant chemotherapyRadical surgery in case of failure

Malignant melanomaHorrible prognosis Dark mass protruding from the anus50% pigmentedLymph node MTS earlyTreatment - not clear advantage of any alternative

Bowens disease:Squamous cell carcinoma in situLike all other places of skinPlaque-like eczematoid lesion + pruritusBiopsy-carcioma in situ + hyperkeratosis and giant cellsTherapy: local excision with safety margins

Basal cell carcinomaUlcerating tumor (uncommon)Rodent ulcer like every other place of skin exposedDoesnt spread distantly Local excision

Pagets diseaseRare conditionPale plaquelike condition with induration + nodular mass (not always)Nodular mass= coloid carcinoma from glands or other skin appendagesLocal excision (without mass)Radical surgery + chemo + RT for coloid carcinoma

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