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.

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: 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.

the 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.

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 prolapse

Complete prolapse

Prolapse is first noted during defaecation.

Discomfort during defaecation.

Bleeding.

Mucous discharge.

Bowel habit irregular and may lead to incontinence.

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!)

Infection Ulceration Severe haemorrhage from

one of the mucosal vein Thrombosis and obstruction of the venous returns leading to

oedema Irreducibility and gangrene

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

Complications 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.

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:

Partial prolapse:

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

Electrical stimulation with sphincteric exercises.

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

Electrical stimulation with sphincteric exercises.

Surgery always necessary, none are ideal.

Thiersch’s operation

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

Surgery always necessary, none are ideal.

Thiersch’s operation

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

Complete prolapse:

Rectal cancerRectal 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

Bleeding per anumSensation of incomplete bladder emptingTenesmusAbdominal painPalpable 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 RECTAL EXAMINATION

SymptomsSymptoms SymptomsSymptoms

InvestigationsInvestigationsInvestigationsInvestigations

StagingStaging::

- - Recto- Recto- and colonoscopy and colonoscopy

- - Barium enemaBarium enema

- CT - CT

- - MRIMRI - - EUSEUS

StagingStaging::

- - Recto- Recto- and colonoscopy and colonoscopy

- - Barium enemaBarium enema

- CT - CT

- - MRIMRI - - EUSEUS

RECTOSCOPY COLONOSCOPY + BIOPSY

Indications

- Suggestive images on barium enema

- Suggestive symptoms of colonic cancer

- Screening

-After polipectomy

COMPUTER-TOMOGRAFIA(aspecte CR)

COMPUTER-TOMOGRAFIA(aspecte CR)

EUSEUS

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

TNM Primary Lymph-node Distant Dukesstage 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

Astler-Collermodified

Dukes stage

Clinical Staging of CRC

TisTis TT11 TT22 TT33 T T44

ExtensionExtensionto an adjacentto an adjacent

organorgan

MucosaMucosaMuscularis mucosaeMuscularis mucosae

SubmucosaSubmucosa

Muscularis propriaMuscularis propria

SubserosaSubserosa

SerosaSerosa

TNM Classification

Stage and Prognosis

Stage 5-year Survival (%)

0,1 Tis,T1;No;Mo > 90I T2;No;Mo 80-85II T3-4;No;Mo 70-75

III T2;N1-3;Mo 70-75III T3;N1-3;Mo 50-65

III T4;N1-2;Mo 25-45IV 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 anastomoticleakage

-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)

Abdomino-perineal resectionMILES

Anterior resection and very low anterior resection

Follow up!!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