Rectum anatomy

 Tenia coli end at the beginning of the rectum and they converge into a continuous muscle layer
 Puborectal sling: enlocses the posterior and lateral aspects of anorectal junction; and creates
the anorectal angle (120 dgree)
 3 curvatures in rectum:

o
 12-18 cm; 3 parts
o Upper part: peritoneum on all sides
o Middle part: peritoneum on anterior and lateral sides
o Lower part: below peritoneal reflection
 Facia in the lower 3rd of rectum
o Between rectum and vagina/prostate anteriorly: denonvillier’s fascia
o Between rectum and sacrum posteriorly: waldeyer’s fascia

Blood supply:

 Superior rectal artery from IMA

 Middle rectal artery from IIA
 Inferior rectal artery from Internal pudendal artery; which is a branch of IIA
Venous drainage: rectum drained by superior rectal vein usually (portal vein)

Lymphatic drainage:

 Notmally para-aortic lymph nodes ultimately

 If they are blocked: flow can reverse: LN found in
o Pelvis: along middle rectal vessels
o In inguinal region: along inferior rectal vesses

Spurious diarrhoea: early morning stool frequency

Tenesmus: I feel I want to go but nothing happens

Proctalgia: severe episodic pain: due to spasm of levator ani muscles

Examination:

 Inspection for fissure/fistula/prolapse/abnormal descent of the pelvic floor

 DRE:
o check the integrity of sphincters: tone and squeeze
o feel for rectocele, tumors in rectum
o examine finger for mucus, pus, blood
o intraluminal: blood/pus
o intramural: tumor, granular areas, stricture
o extramural: enlarged prostate, uterine fibroid

Proctoscope

Sigmoidoscopy: flexible sigmoidoscope now

Trauma to rectum: fall, gunshot/penetrating injury, sexual assault, childbirth: forceps assisted delivery

Prolapse of rectum:

Mucosal prolapse: only protrusion of mucous membrane and submucosa

Mucosal prolapse in children:

 infants:
o vulnerable to prolapse
o no sacral curve
o so predisposed to prolapse
 children:
o cause
 attack of diarrhoea
 weight loss/loss of fat in ischiorectal fossa
o associated condition
 CF
 Neurological disorder
 Hisrchsprung
 Rectal polyp
 Maldevelopment of pelvis
 Adult
o Often assoc with hemorrhoids: if so: its called mucohemorrhoidal prolapse
 Treatment:
o Teach patient to reposit digitally
o Scleroptherapy
o Rubber band ligation
Full thickness proalse:

 Complete rectal prolapse: procidentia (less common than the mucosal variety)
 It contains all layers of the rectal wall
 Associated with
o Weak pelvic floor
o Chronic straining: so associated with constipation as well
 Finger cannot be passed between prolapsed viscera and anal verge

Rectal polyp:

 Most Frequent site of polyps in body: rectum and anal canal

 Adenomatous polyp: can become malignant
 Removal of all polyp + complete histological dx: needed to exclude

What are the rectal polyps?

 Hyperplastic polyps
o 2-4 mm
o harmless
 Tubular adenoma
o Most common type of polyp
o If >1 cm: potentially malignant
 Villous adenoma
o Frond lile appearance
o Can be very large
o More tendency to become malignant
o Profuse mucus discharge: CAN cause electrolyte imbalance
 Serrated adenoma
 FAP (familial adenomatous polyposis)
o Autosomal dominant
o Multiple adenomas in rectum and colon present around puberty
o APC gene mutation
o It is a premalignant condition: if present, toral colectomy within 10 years of onset
 With permanent ileostomy
 Inflammatory pseudopolyp: associated with colitis/other inflammatory conditions
 Juvenile polyp
o Cherry tumor
o Bright red, glistening, spherical
o Pain
o Bleeding if prolapses during defecation
o Very rarely malignant
Treatment as a whole for rectal polyps:
 Exclude cancer by histological analysis

Benign tumors

 Endometrioma
 Hemangioma
 GIST
 Neuro-endocrine tumors

Carcinoma:

 Colorectal cancer: 2nd most common malignancy

 Risk factor
o Diet
o Obesity
o Smoking
o Lack of physical exercise
 Age: old age; mostly 70 y or older

Progression/pathogenesis

 Gradual accumulation of dysplastic changes

 Non familial progression is called: adenoma carcinoma sequence
 Familial
o FAP
o HNPCC (hereditary non polyposis colorectal cancer

Clinical features:

 Early symptoms may be insignificant and thus may be very easily missed
 Early symptoms are
o Bleeding per rectum
o Tenesmus
o Early morning diarrhoea
 Bleeding
o Earliest
o Most common
o Bright red color
o Painless
o Can be mixed with feces
 o Can be in the pan only
o Most common dd of this type of bleeding: hemorrhoids
 Tenesmus
o Sensation of needing to evacuate
o But unable to pass feces
o Early symotom – very common
 Early morning (spurious diarrhoea)
o Pt may feel the urge to pass feces multiple times per day; but mostly at the morning
o Not due to food particle; but due to overnight accumulation of mucus and slime and
blood (bloody slime)
 The above three are classic and most common early symptoms
 Other symptoms
o Alteration of bowel habit
 More frequent defecation
 Passage of looser stool
 Has to get up early in order to defecate
 Passes blood and mucus is addition to feces
 Constipation if: stenosing carcinoma of the rectosigmoid junction
o Pain
 Pain due to obstruction: colicky pain: in case of rectosigmoid junction tumor
 Prostate/bladder anteriorly
 Sacral plexus posteriorly: severe, intractable pain
o Wt loss
 Associated with metastatic dss
 Late symptom

Examination:

 Abdominal
o Signs of obstruction: in case of rectosigmoid junction tumor
 Abdominal distension
o Signs of liver metastasis
 Liver palpable
 Ascites: if there is widespread peritoneal dissemination
 Digital Rectal examination:
o Mass felt if it is situated close to the anal verge (w/n 7-8 cm)
o If ulceration: shallow depression with elevated and everted edges
o Check mobility
o Check distance of the lower margin of tumor from the top of the sphincter complex
o In case of female if there is anteiorr wall involvement: examination of the vagina
 Colonoscopy:
 o If not possible
 CT
 Barium enema can be used

Summary of dx and assessment:

 All pt with suspected rectal cx will undergo:

o DRE
o Colonoscopy + biopsy
o CT
o Barium enema
 Pt with proven rectal cancer: for staging
o Imaging of chest, abdomen, pelvis by CT
o Pelvic MRI/endoluminal ultrasound: for local pelvic imaging

Types of cancer spread

 Local spread
o Circumferentially rather than longitudinally
o Anterior spread: prostate, seminal vesicle, bladder in male and vagina/uterus in female
o Lateral spread: ureter
o Posterior: sacrum and sacral plexus
 Lymphatic spread
o Usually in upward ddirection
o May occur in downward direction if there is lymphatic blockage
 Venous spread
o Liver
o Lungs
o Adrenal glands
o Brain
 Peritoneal dissemination

Duke’s staging:

 A: rectal wall + excellent prognosis

 B: extra-rectal tissues, no LN + reasonable prognosis
 C: LN involvement : poor prognosis
o C1: local LN
o C2: para-aortic LN
 D: not in duke’s”
o Presence of widespread metastasis (usually hepatic)
TNM staging: radiological staging

Histological: grading:

 By nature they are adenocarcinoma

 Well differentiated: less aggressive
 Poorly differentiated: more aggressive
 Infiltration and invasion can also be seen
 Signet ring appearance: poorer prognosis

Treatment:

 Mutli-disciplinary team approach

 Before treatment planning
o Assess pt status
o Extent of spread of tumor
 Pre-operative assessment
o CT of chest, abdomen, pelvis: to exclude distant metastasis
o Liver USG
o PET scanning: metastasis
o Endoluminal USG: probe placed in rectal lumen
 Assess local spread of cancer
o To assess local staging: use MRI rather than CT
Surgery principles:

 Mainstay:
o Radical excision of rectum + mesorectuym + associated LN
 Widespread metastasis: palliation
o Endoluminal stenting
o External beam radiotherapy
o If liver metastasis is well localized: there may be chance of cure in case of liver resection
 If locally advanced: pre-operative radio and chemo-therapy to stage down the tumor
 If there is to be a radical excision
o Try to save the sphincter: Anterior resection: sphincter saving operation: possible if
tumor margin in >2cm above the anorectal junction
 Restore continuity by stapling technique/anastomosis: end to end, side to end
etc…
o If tumor in lower third of rectum, and lower margin less than 2 cm above the anorectal
junction: abdomen-perineal excision: with permanent removal of the anus, rectum and
permanent colostomy

Pre operative preparation:

 Correction of
o Fluid and electrolyte imbalance
 Blood grouping, cross matching, blood collection
 Bowel preparation: cleanse bowel to reduce contamination (diet, purgative, enema)
 Stoma preparation
o Siting
o Counselling
o Warning about complications
 Prophylactic pre=op antibiotics
 Prophylaxis against DVT

Surgical methods:

 Most important
o Anterior resection
o Abdomino-peritoneal excision of the rectum (APER)
 Others
o Local excision
o Transanal total mesorectal excision (taTME)
o Hartmann’s operation
 Palliative procedures
 o Endoluminal stenting: only done in cases of
o Palliative colorstomy

Chemo

Radio

Anterior resection:

 Sphincter saving
 Open abdomen/laparoscopically
 Low anteiror resection: lower dissection line at anorectal junction
 High anterior resection: lower dissection line 3 cm below the cancer; but above the anorectal
junction
 Restoration of bowel continuity done by: stapled anasotomosis

Abdomino peineal resection of rectum (APER)

 No intention of saving sphincter

 Lower third of remtum tumors
 Two dissection: one via abdomen, one via peirineum; at last excision of the lesion thru anal cana
 Perineal dissection
o Circumanal incision made
o also extended posteriorly and anteriorly of the rectal wall (bone, vagina, urinary bladder
etc)
 after resection
o end colostomy: left iliac fossa