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Surgery > Rectal Cancer > Flashcards

Rectal Cancer Flashcards

0
Q

Examination to detect rectal wall defects and blood ?

A

Rectal Examination

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1
Q

Intraperitoneal rectal injury can cause ….

A

Peritonitis

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2
Q

Workup rectal trauma:

A

– Rectosigmoidoscopy

– Water soluble contrast enema

– Contrast enhanced CT scan

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3
Q

Treatment for Anorectal trauma?

A

suture repair (absorbable suture)

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4
Q

Treatment for lower subperitoneal rectum trauma ?

A

Endoanal rectal suture

Perirectal debridement + drainage (high risk of
cellulitis)

Left colostomy (double-barrel colostomy type - to avoid fecal contamination)

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5
Q

Treatment for superior (subperitoneal and

intraperitoneal) rectum trauma ?

A

suture repair through laparotomy + / -

protective colostomy

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6
Q

Epidemiolgy: rectal cancer prevalence?

A

Male > female

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7
Q

Factors that reduce the risk of rectal cancer

development:

A

High fiber diet
Vegetables - protective effect: cabbage
Calcium and Vit. D
Vitamins and antioxidants - vitamin. A, C, E, beta carotene

Other factors:
Coffee
Aspirin
NSAIDs

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8
Q

Factors that increase the risk of rectal cancer

development:

A

High protein diet

– red meat – unfavorable effect

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9
Q

Rectal cancer appears on preexisting ….

A

Adenoma

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10
Q

Which adenoma has the highest risk of malignant transformation ?

A

Villouso adenomas

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11
Q

Macroscopic aspect of rectal cancer:

A

Exophytic ulcerated tumors: common ‼️
________

  • Exophytic tumors: low malignancy
  • Ulcerated tumors: increased malignancy
  • Stenosing tumors
  • Diffuse infiltrative tumors - uncommon
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12
Q

Microscopic aspect of rectal cancer ?

A

•Adenocarcinoma – glandular epithelium with
tubular or villous structures

  • Mucinous adenocarcinoma
  • Signet ring cell carcinoma
  • Squamous cell carcinoma
  • Adenosquamous carcinoma
  • Small cell carcinoma – oat cell carcinoma
  • Undifferentiated carcinoma
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13
Q

Dissemination rectal cancer: local

A

Local Extension

Direction of spread

  • longitudinal
  • circumferential
  • wall penetration

Invasion of the vagina, uterus, adnexas, bladder, seminal vesicles, prostate, ureters, peritoneum – pouch of Douglas

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14
Q

Dissemination of rectal cancer: Lymphatic

A

Lymphatic spread

It begins when the tumor invades the
lymph vessels:
-Submucosal
-Perirectal

Extension - lymphatic vessel permeation –
din aproape în aproape - lymph nodes embolization

Cel mai frecvent:

Ascendent
 ggl mezenterici inferiori
 ggl paraaorticic

Lateral
 ggl fosei obturatorii
 ggl iliaci

Retrograd - ggl inghinali

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15
Q

Dissemination: hematogen - venous

A
  • Low differentiated forms

- Metastasis: hepatic, pulm, gl suprarenal / bones / muscles / thyroid / spleen (rare)

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16
Q

Dissemination: perineural

A
  • invasion of the hipogastric plexus
17
Q

Dissemination: distant

A

The cancer cells leave the tumor and travel to other sites of the lumen

18
Q

Dukes Classification

A

Grad A: tumor limited to rectal wall
Grad B: tumor goes out of rectal wall
Grad C: invasion of regional limphnodes
Grad D: distant metastasis

19
Q

Astler - Coller Classification

A

Tx - not assesed
T0 - no evidence of tumor
Tis - in situ
T1 - invasion lamina propria / submucosa
T2 - muscular invasion
T3 - subserosa invasion ( perirectal tissues w/o peritoneu)
T4 - peritoneal invasion or adiacent organs

Nodes:
Nx - not assesed 
N0 - no adenopathies
N1 - invasion of 1-3 perirectal nodes
N2 - invasion of >3 perirectal nodes

Metastasis:
Mx - not assesed
M0 - without metastasis
M1 - distant metastasis

Stadium:
0 - Tis N0 M0
I - T1, T2 N0 M0
IIA - T3 N0 M0
IIB - T4 N0 M0
IIIA - T1-2 N1 M0
IIIB – T3-4 N1 M0
IIIC – any T N2 M0
IV – any T any N M1
20
Q

Rectal cancer

Clinical

A

Long time asimptomatic

First signs: 
Change in stools - frequency and consistency 
Diarrhea / Constipation 
Fecal incontinence + urge 
Bleeding ‼️ - fresh blood on stool surface
Pain moderate, sporadic 
Inconstant mucous 
Pruritus

Emergency: (1/3 sup rect) ‼️

  • occlusion
  • massive bleeding
  • perforation
21
Q

Rectal cancer

Clinical - advanced

A 
Tenesmus - massive exophytic tumors
Pain = very bad prognostic ‼️
-> invasion of extrarectal nerve plexus and bones 
Rectoragii - anemia 
Incomplete defecation
Anal incontinence 
Recto-vaginal fistula 
Weight loss / anorexia
Jaundice => hepatic metastasis
Lymphadenopathy (cervical, inghinal)
Intestinal occlusion
Perforation / peritonitis 
Rectovezical fistula -> feces/gas through uretra
22
Q

Rectal cancer

Rectal examination

A 
Tumors of inferior rectum are palpable!
How mobil? - depends on infiltration into the wall
Dimension? 
Consistency? Ulceration? 
Lumen occlusion? 
Invasion of adiacent structures? 
Perirectal adenopathy? 
Dimension of prostate?
23
Q

Rectal cancer

Physical exam

A

Abdominal palpation:

Ascitis 
Hepatomegaly = hepatic metastasis 
Massive tumors (1/2 sup)
24
Q

Paraclinical

A 
Tumor presence 
Location?
Biopsy - Histology 
Other tumors or benign adenomas present ? 
Metastasis?
25
Q

Tumoral marker

A

✔️ SCCTA4
✔️ CEA - not specific, post-op: detects recurrences
✔️ CA 19-9
✔️ CA 50

(In studium: CA-72, CA-125/TPA)

Radioimunscintigraphy:
- monoclonal AB (MAb)

26
Q

Screening for rectal cancer

A

Adults over 65 years

Test: occult blood in stools

27
Q

Most important Diagnostic tool:

A

Histopathologic exam

28
Q

Diferential diagnosis:

A

Benign:

  • hemoroids
  • polips
  • benign tumors

Inflamation:

  • Anite
  • Crypts
29
Q

Treatment for rectal cancer:

A

Remove:
Tumoral rectum
Mezorectum
Lymphnodes (regional)

Prevention of recurrence.

Radiotherapy = first intention!
Radical Radiotherapy:
-inoperable tumors (invasion of other organs)
-cardiovascular/respiratory diseases

After reducing the size of the tumor -> surgery

Radiotherapy curative/conservative intention:
-preserve sfincter function

Radiotherapy adjuvant:
-before surgery, to reduce the size of tumor

Radiotherapy palliative:

  • if not operable
  • recurrence or metastasis

Surgical Treatment:
= Initial treatment just when small lesions

Respect 4 anatomical rules:

  • curving of Denonvilliers fascia
  • remove mezorectum
  • section lateral ligaments & medial rectal arteries
  • respect pelvis nervous plexus
30
Q

Treatment - surgery

Superior rectal / rectosigmoidian cancer

A
  1. Rectosigmoidian resection
    - > through anterior abdomen (DIXON)
  2. Then colorectal anastomosis (T-T or L-T)

Possible: Manual or mechanical

31
Q

Surgery

Middle rectal ampula cancers

A

Rectosigmoidian resection abdomino-perineal / endoanal -> pulling down transfincterian of the colon -> colon anastomosis
(saving the sphincter - BABCOCK - BACON)

32
Q

Surgery

Inferior rectal ampula

A

.

33
Q

Surgical treatment

Palliative

A

Indication:

  • Massive extension of tumor
  • Metastasis (hepatic / pulmonary)
34
Q

Rectal cancer

Chemotherapy

A

Tumors of digestive tract do not response well to chemotherapy❗️

5-FU = anti-tumoral agent
(mono-therapy / association)

35
Q

Surgical treatment

Rectal cancer complication: occlusion

A

3 steps solution:

  1. Colostomy
  2. Tumor resection
  3. Close colostomy + reconnect remaining parts

2 steps solution: = HARTMANN❗️

  1. Resection of sup rectal tumor + closure of distal rectum with proximal colostomy
  2. Reconnection of rectum to transit
36
Q

Surgical treatment

Rectal cancer: perforation

A

Possible perforation:

  • at tumor level through necrosis
  • at the cecum (diastatic perforation) -> do total colectomy with ileo-rectal anastomosis‼️
37
Q

Middle ampullary cancer resection

Name der prozedur?

A

BABCOCK - BACON

  • > danach: colo-anal anastomose
  • > rettung des schließmuskels ‼️
38
Q

Sup rectal cancer / rectosigmoid cancer

Radical intention

Name der prozedur?

A

DIXON

  • > danach: colo rectal anastomose
  • > mechanisch oder manuell
39
Q

Rektum amputation

Bei: unterem ampula rektum krebs

A

MILES

  • mit linkem iliac anus
  • > danach: colo-anal anastomose
  • > KEINE rettung des Schließmuskels ‼️ komplette resektion des inneren analen Schließmuskels

Surgery (17 decks)

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