3. ● Surgery is the mainstay of curative therapy
● The primary resection consists of rectal resection performed by total mesorectal excision
● Most cases can be treated by anterior resection, with the colorectal anastomosis being achieved with a circular
stapling gun
● A smaller group of low, extensive tumours require an abdominoperineal excision with a permanent colostomy
● Preoperative radiotherapy with or without chemotherapy can be used to down-stage the cancer and reduce local
recurrence
● Adjuvant chemotherapy can improve survival in node-positive disease
● Liver resection in carefully selected patients offers the best chance of cure for single or well-localised liver
metastasis
SURGICAL PRINCIPLES
5. SURGICAL MANAGEMENT
ABDOMINOPERINEAL RESECTION
o The sigmoid , descending and upper rectum is mobilised per abdominally .
o Anal canal with perianal and perirectal tissues are dissected per anally .
o Retained colon is brought out as end colostomy in left iliac fossa
o Done through lower mid line incision in lithotomy position .
o Rectum is mobilised posteriorly in avascular plane in front of nerve plane between
mesorectum and sacrum .
o Colon is transected and proximal cut end is fashioned for end colostomy in left iliac
fossa.
o Circumferential incision is placed around the anus.
o Anterior dissection is done to reach above and specimen is removed through
perineal wound.
o Colostomy is created by suturing skin to mucosa using silk / vicryl
6. APR - TYPES
MILES GABRIEL
Abdomen first , perineum later
Synchronised , combined
Perineum first, abdomen later
LLOYD-DAVIES
8. INDICATIONS
FOR APR
It is the treatment of choice when :
Mesorectum is involved
When it is poorly differentiated
tumour
When nodes are involved.
It gives adequate clearance
9. SPHINCTER SAVING APR WITH COLOANAL
ANASTOMOSIS
Done in operable distal rectal tumour in young individuals wherein anal sphincter need
not be sacrificed but adequate oncological tumour clearance can be achieved
Entire rectosigmoid is removed retaining only the anal sphincter
Colonic J-pouch or coloplasty reservoir is created in the mobilised descending colon
Coloanal anastomosis is done per anally using hand sutures under direct visualisation
Here a permanent colostomy stoma is avoided
10. APR WITH NEO SPHINCTER
RECONSTRUCTION
This is technically difficult with complications
Perineal colostomy is done with gracilis muscle wrap which is made to
produce sphincter like muscle, twitch using an implanted pacemaker
11. COMPLICATIONS OF APR
Bleeding
Infection of perineal wound
Complications of colostomy like prolapse ,
stenosis and infection
Injury to the urinary system , ureter ,
impotence , urinary incontinence
Operative mortality < 2%
12. ANTERIOR RESECTION
• It is done in growths located in the mid and upper part of the
rectum , which is well differentiated, small sized and with clear
adequate length for anastomosis after resection.
• It is also called anterior proctosigmoidectomy through abdominal
approach where in the rectum above the peritoneal reflection is
resected with colorectal anastomosis.
• Low anterior resection (LAR) is the resection of rectum below
the peritoneal reflection along with the sigmoid colon , with total
mesorectal excision through abdominal approach and colorectal
anastomosis using circular stapler device ( EEA stapler)
13. CRITERIA FOR
ANTERIOR RESECTION
Upper and middle third rectal growth
Above peritoneal reflection
Well differentiated tumour , < 4cm sized
tumour
In females , growth 7cm above the anal
verge
T1 N0 / T2 N0 tumour
Tumour without lymphatic or venous spread
14. DISADVANTAGES
Can avoid permanent colostomy
Sphincter is retained
More patient acceptance
ADVANTAGES
× Uncertainty of clearance , chances of local
recurrence is high
× Anastomotic leak , infection , stenosis
× LAR syndrome-frequent small bowel movements
causing more frequent stools (can be avoided by
creating reservoir by doing colonic J-pouch or by
doing coloplasty 6cm from the proximal divided
end of colon)
15. TRANSANAL TOTAL MESORECTAL EXCISION (ta TME)
• The trauma of anterior resection can be reduced by undertaking total
endoluminal excision of the rectum
• It builds on the principle of laparoscopic surgery, with an airtight anal device
used to provide transanal insufflation and access for laparoscopic
instruments
• A purse-string suture is placed below the distal level of the tumour and the
bowel wall in incised to enter the mesorectal plane. Dissection then
proceeds using a ‘bottom-up’ approach to accomplish TME
• Ssimultaneously a ‘top-down’ laparoscopic resection is done by an
abdominal operator who mobilises the left colon takes down the splenic
flexure and does some of the upper rectal dissection
16. HARTMANN’S OPERATION
It is a palliative procedure done is elderly people who are not fit for major surgery
like AP resection and also in locally advanced tumours
Rectal growth is resected and upper end of rectum is closed completely
Proximal colon is brought out as end colostomy
17. It is the removal of rectum with the tumour , all the lymph nodes , urinary bladder, fat, fascia,
uterus, vagina, with colostomy and urinary diversion
PELVIC EVISCERATION (BRUNSCHWIG’S OPERATION)
18. PALLIATIVE COLOSTOMY
• It is done in advanced unresectable growth which presents with intestinal obstruction
20. RADIOTHERAPY
Only rectal adenocarcinoma in GIT responds well for RT
Preoperative RT can be given to down stage the tumour so as to make it amenable for APR
or make it for anterior resection
RT sterilises field; causes down staging of tumour; preserves sphincter
For rectal cancer, usually combined chemoradiotherapy is given. It is given in the
neoadjuvant setting
In small well differentiated growths Papillon’s intracavity curative radiotherapy can be tried
with proper follow-up
Short course: 5-6 days chemoradiation → surgery
Long course: 5-6 weeks chemoradiation → wait for 5-6 weeks → surgery
21. IMMUNOTHERAPY
Used only in metastatic or recurrent colorectal cancers
The agents used are:
Bevacizumab: monoclonal antibody against VEGF
Cetuximab: monoclonal antibody against EGFR
Panitumumab: monoclonal antibody against EGFR
Pembrolizumab, Nivolumab: PDL-1 inhibitors (used in microsatellite instability)
22. OTHER METHODS
o Electrocoagulation and decoring of the tumour, as a palliative
procedure; stenting.
o Laser photocoagulation, cryotherapy.
o Portal vein infusion; hepatic artery infusion for metastases.
o Tumour vaccines: Tumour antigen does not elicit immune response in
situ; but vaccines are injected to evoke immune response.
• BCG with irradiated tumour cells
• Monoclonal antibodies 17-1A (Murine lg G2A);
• CEA vaccines.
23. PROGNOSIS IN CARCINOMA RECTUM
5 YEAR SURVIVAL RATE PROGNOSTIC FACTORS FOLLOW-UP
STAGE I 90%
STAGE II 75%
STAGE III 40%
STAGE IV 5%
Size of the tumour
Differentiation
Mesorectal involvement
Stage of the disease
Nodal status, perineural spread
Distant spread
Circumferential resected margin
Adjuvant therapy used
Regular
Colonoscopy
CEA assessment
( carcinoembryonic antigen)
PET scan
MRI / CT scan
Colostomy care in APR
