Begum Surgical option for Ca rectum Pt 4 Principles Radical excision of the tumour Rectum Total mesorectal excision TME Associated lymph nodes High proximal ligation of inferior mesenteric ID: 930791
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Slide1
Lower GIT 3
Dr.
Mahbuba
Begum
Slide2Surgical option for Ca rectum ( Pt 4 )
Principles
:
Radical excision of the
tumour
/ Rectum
Total
mesorectal
excision ( TME )
Associated lymph nodes
High proximal ligation of inferior mesenteric
lymphovascular
pedicle.
Resection margin – proximally 5 -7cm from proximal margin of growth, distally – in high resection 3 -5cm from distal margin of growth & in low resection at least 2cm.
Procedures : Sphincter saving
I ) Anterior resection
– for
tumour
in upper & middle 3
rd
of rectum. Now even possible for
tumour
whose lower margin is ≥ 2cm above
anorectal
junction. ►
Slide31) High anterior resection
–
rectosigmoid
tumour
/ in upper 3
rd
of rectum
continuity maintained by colorectal
anastomosis
- hand sewn single layer interrupted
- stapler
anastomosis
2) Low anterior resection
– for middle 3rd even in lower 3
rd
growth with complete removal of rectum provided 2cm healthy margin distally.
Continuity by stapling
anastomosis
.
Ultra low anterior resection
– for lower 3
rd
rectal growth with removal of rectum.
Continuity by
abdomino
transanal
coloanal
anastomosis
by stapling, end to end, side to end or
colopouch
anus
anastomosis
.
Anterior resection is associated with
temporary loop
ileostomy
to safe guard the
anastomosis
( covering /
defunctioning
/ diversion stoma)
Slide4Anterior resection syndrome
– problems in low resection
Defaecatory
urgency
Incontinence
Incomplete evacuation.
II )
Abdominoperineal
excision of rectum ( APR / APER )
– growth in the lower 3
rd
of rectum & unsuitable for sphincter saving procedure.
Combined
laparotomy
&
perineal
procedure
Pt in
Trendelenburg
lithotomy
position /
Lloyed
– Davies position
Permanent end colostomy in left iliac
fossa
Perineal
wound closed.
Methods of operation
: open / laparoscopic hand assisted.
Other procedures
– palliative in advanced Ca
Hartmann’s operation
– rectum is excised, distal stump closed & proximal end brought out as colostomy, when concern about sphincter function or viability of
anastomosis
. Option for old & frail patient.
Slide52 ) palliative colostomy
– for intestinal obstruction with gross infiltration. After
chemoradiation
– definitive procedure
Local procedures
– organ saving ►
Trans anal excision
– TEMS – trans anal endoscopic microsurgery – for low grade T1 ( even T2 )
tumour
.
Laser destruction
–
intraluminal
debulking
in obstructing or bleeding lesion.
Interstitial radiation
–
brachytherapy
Endoluminal
stenting
– to relieve obstruction of colon & upper rectal Ca.
4 ) pelvic
exenteration
– extensive operation for local spread. Removal of all the pelvic organs – total hysterectomy in female,
cystectomy
in male with urinary diversion.
Slide6Other modalities of treatment
Chemotherapy
Neoadjuvant
± RT – for down staging
Adjuvant – to reduce / prevent recurrence in node positive pt
After palliative surgery.
Radiotherapy
Neoadjuvant
± CT - ↓ size of large
tumour
.
Adjuvant - ↓ local recurrence
Palliative – inoperable primary
tumour
, painful local recurrence.
Immunotherapy
– Monoclonal
Ab
- for treatment of disseminated colorectal Ca.
Watch & wait management
:
chemoradiotherapy
or radiotherapy for locally advanced malignancy – to down stage the cancer & ↑ the chances of a complete resection with clear
oncological
margins. ►
Slide7► in complete clinical response with no evidence of residual Ca on C/E, imaging or biopsy – watch & wait ( to avoid morbid operation ) → intense surveillance → 30% recur → surgical resection.
D / D of rectal ulcer
Carcinoma
TB
Solitary rectal ulcer
Amoebic
Carcinoid
D /D of rectal
sricture
Carcinoma
Amoebic
TB
Ulcerative colitis
Crohn’s
disease ►
Slide8LGV –
lymphogranuloma
Venerium
,
Chlamydial
infection
Endometriosis .
Prognosis
: depends on stage. Overall 5 year survival – 50%
Follow up
: 3 monthly for 2 years, 6
monthy
for 3 years, yearly for lifelong.
- history ( F/ recurrence, F/metastasis ), Exam . – stoma, D/R/E, Investigation – CEA, USG of Whole abdomen.
Screening
of colorectal malignancy : early detection , offer curative resection , ↓ mortality & morbidity.
D/R/E
Faecal
occult blood test
Colonoscopy ± biopsy.
Slide9Surgical option in emergency presentation (obstruction ) of colorectal malignancy
: Pt 3
After preoperative
resuscitation
, emergency exploratory
laparotomy
done, procedures depends on
intraabdominal
status, pt’s general condition & surgical skill.
►
Colostomy
- sigmoid / transverse loop – when primary resection not possible for left sided growth.
Bypass
–
eg
.
ileo
transverse in
rt
sided
irresectable
growth ( Ca
caecum
/ ascending colon ).
Hartmann’s procedure
Resection
(
hemicolectomy
)
with primary
anastomosis
& proximal
temprary
defunctioning
loop stoma
( for left sided growth) after
on table large bowel
lavage
.
Further management
by multidisciplinary team action → definitive procedure ( if not already done ) depending on feasibility.
Slide10Complications of colorectal malignancy in delaying treatment
Intestinal obstruction
Perforation – peritonitis /abscess
Bleeding
Direct
extention
→ fistula.