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etiology anal cancer
SCC associated w/ HPV, tobacco in women
macro aspects of tumours
ulcerative, infiltrative, vegetative
what is more rapid and frequent in rectal vs colon cancer
penetration
most rectal cancers are ________ histopathologically
adenocarcinomas
symptoms based on stages
initial stage - asymptomatic
medium - rectal bleeding (jelly), pain, tenesmus, bowel habit changes (diarrhea if villous, caliber change)
advanced - intense pain (sacral penetration), colicky pain (obstruction), hypogastric + perineal pain, anal incontinence, fistulas, jaundice (metastasis), impregnation signs, compressive edema lower body
physical exam
digital rectal exam
how to assess penetration
tumour mobility on rectal exam
how to physical exam metastasis
groin lymph node palpation
why should vaginal digital exam be done
penetration into post vagina
investigations
rectoscopy w/ biopsy, endocrectal US (for penetration), CT/MRI (for staging), abd us (for metastasis), IV urography (fistula or metastasis), cea (follow up after surgery)
treatment
multimodal - surgical and adjunctive oncotherapy
In cancers located in the lower part of the rectum, what is recommended initially then after
preop radiotherapy for reduction then surgery after 4-6w
surgical treatment
excision of tumoral rectum + lymphadenectomy (total mesorectal excision for tumours in stage II-III)
extension of resection in surgery
tumour should be resected at least 5cm from anal verge, up to inf margin
what if tumour is under 5cm limit
anal sphincter can’t be saved, rectal amputation is major indication
important step in sphincter preserving surgery
introduction staplers for colorectal anastomosis that enabled lowering as much as possible the anastomosis line near anus
the indicated operation in anorectal cancers
abdominoperineal resection (rectal amputation)
types of radical operations
low ant resection w/ colorectal (Dixon’s) anastomosis w/ or w/o temporary colostomy or ileostomy for anastomosis protection
ultralow resection w/ peranal or intersphincterian anastomosis (Parks)
abdominoperineal resection (Miles) w/ l iliac anus colostomy
pullthrus
hartmann
endoluminal excision (early stages)
types of palliative operations
colostomy, cecostomy, ileostomy
palliative resection Hartmann I
types of approaches for surgery
classic (median laparotomy), lap, endoluminal (endoscopy)
pull-thru operation procedure
rectum cut under tumour
colon pulled thru anus (sphincter preserved)
exteriorized colon cut and sewn to anal canal
resection of rectum and colorectal anastomosis is more difficult in who
men
cleavage plane (holy plane) facilitates the
total mesorectal excision
operations for tumours under 5-6cm
abdominoperineal resection
colo-anal anastomosis (intersphincteric)
pull thru
advantages of mechanical suture (staplers)
safe in difficult to reach areas
less risk rectal amputation
decreases operation time, blood loss, contamination
postop complications after low ant resection
anastomotic fistula → peritonitis (prevented w/ temp colostomy or ileostomy)
bleeding
intestinal obstructions
transient urinary dysfxn
sex dysfxn
abdominoperineal resection (Miles)
removal entire rectum + anal sphincter + mesorectum + nodes = iliac anus
indications abdominoperineal resection (Miles)
anorectal or very low rectal cancer
2 approaches to abdominoperineal resection (Miles)
abd - rectum + mesorectum prepared down to levator ani m
perineal - anorectum completely freed up and removed
transanal excision of rectal tumour can only be performed if
tumour in stage 0 or 1, doesn’t occupy more than 1/3 circumference of rectum, no nodes, no involved sphincter
in ____________, Rectal wall is excised in its entire thickness at least at 1 cm away from the lesion being followed or not by suture of the subperitoneal rectum
transanal excision of rectal tumour
anal fissure symptoms
severe pain during and after defecation, malodorous discharge
causes anal fissure
trauma by constipation/others or repeated diarrhea, stress
location anal fissure
post region, in front in women
evolution anal fissure
usually heal or chronic → intersphincteric abscess, fistula, vicious circle from continuous spasm
complications anal fissure
bleeding, abscess, perianal fistula
diagnosis anal fissure
digital + rectoscopy
treatment anal fissure
conservative - sitz baths, ointments, diet
botulinum toxin
surgical - stop vicious cycle, partial lat int sphincterotomy
______ are located at hrs 3,7,11 in gyno position
hemorrhoids
risk factors hemmorhoids
constipation, diarrhea, prolonged standing/sitting, rectal cancer, htn, pregnancy
internal vs external hemorrhoids
above/below dentate line
hemorrhoid symptoms
only symptomatic if complications - bleeding, prolapse → necrosis, ulcer, suppuration, hemorrhoidal thrombosis, skin tags
diagnosis hemorrhoid ivnestigation
digital exam (check prostate too), anorectoscopy
surgery hemorrhoids
if advanced/complications → rubber band ligation for int, sclerotherapy, laser, cryotherapy
surgery in advanced/complicated cases hemorrhoids
hemorrhoidectomy or hemorrhoidopexy, thrombus removal, transal deartarterialization
anesthesia of most hemorrhoid surgeries
spinal anesthesia
postop complications hemorrhoids
early - acute urinary retention, hemorrhasge
late - secondary hemorrhage, anal stenosis or fissure
anal fissure, hematoma or prolapsed thrombosed int hemorrhoid or following injection anesthesia are causes of
anoperineal abscess
evolution perianal abscess
intersphcinter → perianal → ischiorectal → high interm → pelvirectal
clinical pic perianla abscess
celsian signs, painful, fluctance or ulcerated or fistula skin
fourniers gangrene
abscess progresses to severe form
diagnosis perianal abscess
intrarectal us if deep but otherwise clinical exam
treatment perianal abscess
surgery + atb, if interpshrincteric or supralevator pus discharged
postop evoluation perianal abscess
dressings changed every day, complication perianal fistula
supralevator abscess treatment
transal incision, drainage tube
clinical picture perianal fistula
history of pain or intervention, discharge, ext opening, digital exam shows fibrous tract under skin
investigations anoperineal fistula
anoscopy
most common aanoperineal fistulas
intersphincteric and transsphincteric
goodsall’s rule
anterior fistula has direct track to anal canal, post fistula has curved path
treatment anal fistula
never heals spontaneously
surgery - fistulotomy (cutting tract, most common for simple), fistulectomy (excising tract), seton placement
postop complications anal fistula
early - urinary retention, bleeding hemorrhoidal thrombosis, fecal impaction
delayed - recurrence, anal incontinence or stenosis
to prevent recurrences what conditions must be med in anal fistula
complete fistulectomy, int orifice should be discovered, wound healing must happen (dressing) from depth to surface