← All decks
General Surgery
Perspective on Rectal Cancer (A)
Built from Maingot's Abdominal Operations
What’s inside
10 sections · 123 slides
Overview
- What this deck covers
- Terms used throughout
- Terms used throughout (continued)
Cancer of the Rectum
The standard operation, and what changed it
- The long-standing operation for rectal cancer
- Sphincter preservation versus permanent colostomy
- Advances that widened the surgical options
- Factors that determine the surgical approach
- Stage and location lead the decision
Patient Evaluation
Examination and imaging before any plan is made
- Aims of pretreatment evaluation
- Complete colonoscopy before treatment
- Information gained from digital rectal examination
- Proctoscopy and distance from the anal verge
- Endorectal ultrasound in early rectal cancer
- Cross-sectional imaging of the pelvis
- MRI in locally advanced rectal cancer
- CT for locoregional staging
- Tests for distant metastasis
- Course of the rectum through the pelvis
- The rectum's neighbours in the male pelvis
- Levator muscle and the anal sphincters
- The mesorectum and the fascia propria
- Depth of invasion through the bowel wall
- Deciding between local therapy and radical surgery
Local Excision
Taking out the tumour without taking out the rectum
- Patients suitable for local excision
- Two ways of excising a tumour through the anus
- Reach and outcome of the two techniques
- Restricting local excision to distal early cancers
- Clinical selection before local excision
- Pathological criteria for accepting local excision alone
- Findings that mandate radical surgery after local excision
- Chemoradiation after local excision of T2 tumours
- Clinically staged T2N0 tumours
- Chemoradiation before local excision
Total Mesorectal Excision
Removing the rectum inside an unbroken envelope
- Indications for total mesorectal excision
- Sharp dissection in the areolar plane
- Consequences of blunt dissection
- Protecting the hypogastric nerves and pelvic plexuses
- Rectal perforation during dissection
- Completeness of the mesorectal excision and recurrence
- Distal mesorectal spread and the 5-cm rule
- Tumour-specific mesorectal excision
- The mesorectum ends above the anorectal ring
- Restoring bowel continuity after excision
- Distal resection margin in the bowel wall
- Circumferential resection margin and the need for APR
- When removal of the anus becomes necessary
- The intersphincteric plane in an infiltrated sphincter
- Assessing levator and sphincter involvement
- Local recurrence after abdominoperineal resection
- Tumour left behind at the levator hiatus
- Cylindrical abdominoperineal resection
- Rationale and result of the cylindrical operation
- Prone jackknife position for the perineal dissection
- Permanent colostomy after removal of the rectum and anus
- Candidates for a hand-sewn coloanal anastomosis
- The transanal approach to the distal rectum
- Dissection in the intersphincteric space
- Sequencing the transanal and abdominal stages
- Diverting loop ileostomy after a low anastomosis
Minimally Invasive Excision
Keyhole and robotic routes to the same operation
- Aims of minimally invasive rectal surgery
- What dictates the length of the incision
- Effect of a keyhole or robotic mesorectal dissection
- Patient position and access for laparoscopic excision
- Steps of the laparoscopic vascular dissection
- Structures at risk during vascular division
- Mobilising the left colon and splenic flexure
- Reasons for full left colon mobilisation
- Opening the areolar plane at the promontory
- Completing the pelvic dissection
- Denonvilliers' fascia and the anterior plane
- Technical difficulties of laparoscopic excision
- What the robotic platform adds
- Limitations of the robotic approach
Radiation and Chemotherapy Before Surgery
Improving local control before the knife
- Pelvic radiation and local tumour control
- Radiation before surgery rather than after
- United States guideline schedule
- Which patients the United States guideline covers
- European risk stratification on MRI
- The three European treatment groups
- Extended surgery for the highest-risk group
- Linear accelerator in a radiotherapy treatment room
Patients With Metastatic Disease
When the cancer has already spread
- 1 in 3
- Factors that shape treatment in metastatic disease
- Multimodality therapy for resectable metastases
- Treatment sequence in the asymptomatic patient
- Radiation for a high-risk primary tumour
- Synchronous versus staged resection
- Order of operations in a staged resection
- Symptomatic patients with resectable metastases
- Asymptomatic patients with unresectable metastases
- Palliative options for symptomatic unresectable disease
- Choosing among palliative procedures
Cancer of the Anus
A disease that moved from the operating theatre to the radiotherapy suite
- Change in the primary treatment of anal cancer
- The surgeon's role in anal cancer
- Breadth of knowledge the surgeon needs
- Tumours grouped by location, not by biology
- Boundaries of the anal canal and anal margin
- Classifying a tumour as canal or margin
- Treatment follows histology, not the label
- Overlapping epithelia in the anorectal region
- Squamous carcinoma found only in mesorectal nodes
- Squamous cell carcinoma of the anus under the microscope
- Keratin pearl in anal squamous cell carcinoma
- Anal cytology and high-resolution anoscopy
- Ablation of high-grade squamous intraepithelial lesions
- Vaccination against the causative virus
- Assessment after chemoradiation for anal cancer
- Current follow-up practice
- 20-30%
- Salvage surgery after failed chemoradiation
- Planning the salvage operation
- Extent of resection in salvage removal of the anus
- Perineal wound problems and reconstruction
Summary
What to carry away
- Key points on rectal cancer
- Key points on treatment sequence and anal cancer
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition