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General Surgery
Cancer of the Rectum
Built from Maingot's Abdominal Operations
What’s inside
18 sections · 181 slides
Overview
- How this deck is organised
Scale of the problem and how the operations began
Numbers first, then the surgeons who shaped the modern operation
- 149,000
- Definition and site of the tumour
- Landmark operations for rectal cancer
- Contributions of Miles and Heald
Who gets rectal cancer
Family, bowel inflammation, inherited syndromes and lifestyle
- Baseline, family and lifestyle risk
- Colorectal cancer risk in inflammatory bowel disease
- Surveillance and surgery in ulcerative colitis
- Familial adenomatous polyposis
- Hereditary nonpolyposis colorectal cancer
- Cancer risks in Lynch syndrome
- Screening and surgery in Lynch syndrome
Polyps and the adenoma-to-carcinoma sequence
How a benign lump becomes an invasive cancer, and when polypectomy is enough
- The adenoma-to-carcinoma sequence
- Genetic steps and the time course of polyp change
- Histologic types of adenoma and polyp size
- Screening the rectum and the rest of the colon
- Depth of invasion in a pedunculated and a sessile polyp
- Managing the malignant rectal polyp
Surgical anatomy of the rectum
Landmarks, blood supply, lymphatics, nerves and the fascial planes
- Extent, peritoneal covering and fixation of the rectum
- Anatomic landmarks of the rectum and anal canal
- Muscular landmarks of the anorectal ring
- Measuring the height of the tumour
- The anorectal ring and sphincter preservation
- Arterial supply of the rectum
- Arterial supply and venous drainage of the rectum and anus
- The middle rectal artery and the lateral stalks
- Lymphatic drainage of the rectum
- Lymph node groups draining the rectum and anus
- Zones of upward and downward spread
- Pelvic autonomic nerve supply
- Autonomic nerve supply of the pelvic organs
- Organs supplied by the inferior hypogastric plexus
- Fascial planes of the pelvis
- Fascial planes surrounding the rectum
Diagnosis and clinical assessment
What the history, the finger and the rigid scope tell you
- Symptoms at presentation and what they signal
- Medical, functional and family history
- Digital rectal examination and rigid proctoscopy
- Limitations of flexible endoscopy, and the rest of the colon
Imaging and staging investigations
How deep, which nodes, and has it spread
- Order of the preoperative workup
- Computed tomography of the abdomen and pelvis
- Chest imaging, blood tests and carcinoembryonic antigen
- Endorectal ultrasound of the primary tumour
- Five wall layers seen on transrectal ultrasound
- Ultrasound appearance of a tumour confined to the rectal wall
- Accuracy and limitations of endorectal ultrasound
- Ultrasound staging categories for rectal tumours
- Magnetic resonance imaging in pretreatment assessment
- Magnetic resonance appearance of tumour invading mesorectal fat
- What magnetic resonance imaging adds
- Positron emission tomography
TNM staging and prognosis
Depth, nodes, distant spread - and what each predicts
- Purpose of staging and the four stage groups
- Tumour and node categories in rectal cancer staging
- Node and distant metastasis categories
- Stage groups from stage 0 to stage III-B
- Stage groups III-C and IV with staging notes
- Depth of invasion and the risk of nodal spread
- Features that worsen prognosis
- Five-year survival by stage after curative resection
Principles of treatment
Matching operation to tumour, preparing the bowel, and the margins that matter
- Matching the operation to stage and site
- Selecting patients for preoperative chemoradiotherapy
- Bowel preparation before rectal surgery
- Antibiotic prophylaxis
- Antibiotic cover for high-risk cardiac lesions
- Goals of surgery for rectal cancer
- Distal resection margin
- Circumferential radial margin
- Consequences of a positive radial margin
- How much mesorectum to remove
Local excision of early rectal cancer
Cutting out the tumour through the anus, and who it suits
- Retrospective and single-centre experience
- Recurrence and survival after local excision with adjuvant therapy
- The CALGB 8984 multicentre trial
- Preoperative T stage and the choice of operation
- Selecting patients for local excision
- Tumour characteristics that permit local excision
- Neoadjuvant therapy before local excision of T2 disease
- Matching the approach to the height of the tumour
- Local excision when the pathology is adverse
- Approaches to local excision and transanal set-up
- Transanal excision: the excision and closure
- Marking and full-thickness transanal excision of a rectal tumour
- Orienting the excised specimen for the pathologist
- Transcoccygeal excision: exposure
- Transcoccygeal excision: removing the tumour and closing
- Posterior approach opening the rectum to reach an anterior tumour
- Posterior approach to a tumour on the back wall of the rectum
- Transanal endoscopic microsurgery: equipment and technique
- Cautions with transanal endoscopic microsurgery
- Oncologic results of transanal endoscopic microsurgery
- Comparing microsurgery with standard transanal excision
- Choosing between the two transanal techniques
Total mesorectal excision: the evidence
Why the fatty envelope around the rectum decides local control
- What total mesorectal excision means
- Completeness of the mesorectal specimen
- Preoperative radiotherapy and national audit of the technique
- Long-term outcome after chemoradiotherapy and mesorectal excision
- Overall survival after preoperative therapy and mesorectal excision
- Recurrence-free survival after preoperative therapy and mesorectal excision
- Lateral nodal spread in distal rectal cancer
- Three-space lateral nodal dissection
- Recurrence patterns with mesorectal excision, radiotherapy and lateral dissection
- Radiotherapy versus lateral nodal dissection
- Sexual and urinary function after rectal cancer surgery
- Quality of life after low anterior resection
Technique of total mesorectal excision
From positioning the patient to dividing the rectum
- Preparation and positioning
- Patient position giving access to both abdomen and perineum
- Opening the abdomen and mobilising the sigmoid
- Dividing the colon and its blood supply
- Mobilisation of the left colon and division of its vessels
- Entering the posterior plane
- Opening the pelvic peritoneum and the posterior avascular plane
- Anterior and lateral dissection
- Dividing the lateral stalks and the planes of pelvic dissection
- The lateral stalks, hypogastric plexus and anterior plane
- Choosing the point of transection
- Tumour position relative to the dentate line after mobilisation
- Dividing the mesorectum and the rectum
Reconstruction and recovery
Rejoining the bowel, protecting the join, and life afterwards
- Preparing the proximal colon and placing the anvil
- The double-stapling sequence
- Dividing the rectum and seating the anvil in the colon
- Introducing and firing the circular stapler
- Assembling the stapler and the completed colorectal anastomosis
- Checking the anastomosis and diverting it
- Drains, closure and reversing the ileostomy
- Postoperative care after low anterior resection
- Function after a very low anastomosis
Abdominoperineal resection
When the sphincter cannot be saved
- What an abdominoperineal resection removes
- Survival, recurrence and life with a colostomy
- Abdominal phase and the perineal incision
- Planes of pelvic floor resection, anal closure and perineal incision
- Freeing the rectum from the pelvic floor
- Entering the pelvis through the anococcygeal ligament
- The anterior dissection and delivering the specimen
- Transection of the pelvic floor and completion of the perineal dissection
- Omentum, colostomy, drains and perineal closure
- Cylindrical abdominoperineal excision
- Aftercare, wound and stoma complications
Extended resection and advanced disease
When the tumour has taken hold of neighbouring organs
- Posterior vaginectomy with rectal resection
- Removing the posterior vaginal wall with the rectal specimen
- En bloc prostatectomy
- Total pelvic exenteration
- Pelvic exenteration for locally advanced disease
- Prophylactic bilateral oophorectomy
- Options in symptomatic stage IV disease
- Palliative resection in stage IV disease
- Resection in asymptomatic stage IV disease
- Laparoscopic surgery for rectal cancer
- Current position on laparoscopic rectal resection
- Non-surgical local treatments
Complications and recurrent disease
What goes wrong, how to spot it and what to do
- General complications and sexual dysfunction
- Anastomotic leak: risk and presentation
- Anastomotic leak: investigation and management
- Presacral bleeding and urinary dysfunction
- Obstructing and metastatic rectal cancer
- How local recurrence presents
- Working up and treating a recurrence
- Palliation of recurrent disease
Chemoradiation and surveillance
Treatment before or after surgery, and how patients are followed up
- Rationale for adjuvant therapy and the early trials
- Chemotherapy added to postoperative radiotherapy
- Advantages of neoadjuvant chemoradiation
- Preoperative radiotherapy trials in the Netherlands and Sweden
- The German Rectal Cancer Trial
- Sphincter preservation and toxicity in the German trial
- Short-course versus long-course radiotherapy
- The EORTC 22921 trial
- Current practice recommended by the authors
- Recommended chemoradiation by stage after radical resection
- Timing of recurrence after curative resection
- Follow-up schedule after curative resection
Take-home points
The ideas worth carrying out of this topic
- Take-home points on anatomy and staging
- Take-home points on choosing the operation
- Take-home points on multimodality therapy
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- Maingot's Abdominal Operations, 12th Edition