Carcinoma Rectum And Anal Canal Laparoscopic Notes

Rectum And Anal Canal

The rectum starts at the rectosigmoid juction, opposite the third piece of the sacrum It descends in the sacral hollow, passes through the pelvic floor, and ends in the anorectal junction, which is about 4 cm away from the anal verge. Anorectal junction is encircled by puborectalis muscle posteriorly and in the lateral aspects. The rectum is 12–15 cm in length.

Read And Learn More: Gastrointestinal Surgery Notes

Some Interesting Features Of Rectum

1. Rectum means straight, but it is not
2. Coverings of the peritoneum are different at different levels.
3. Even though it is a part of the large intestine, taenia, appendices epiploicae and sacculations are absent.
4. The middle curve marks the anterior peritoneal reflection.
5. It is about 12–15 cm above anus.
6. Rectal carcinoma has high recurrence rates because of lack of serosal layer and close relation to other pelvic viscera.
7.  Principal route of lymphatic drainage is upwards towards para-aortic nodes.

Peritoneal Covering

• The upper one-third is completely covered by peritoneum (>11 cm from the anal verge).
• The middle one-third is covered in front and lateral aspects (6–11 cm).
• The lower one-third (0–6 cm) has no extraperitoneal covering but has two fascial condensation layers. Posteriorly, the strong Waldeyer’s layer separates the rectum from the lower sacral pieces and coccyx.
• At surgery, stripping of this fascia results in uncontrollable bleeding from the sacral plexus of veins, which is underneath the Waldeyer’s fascia.

• Anteriorly, the weak Denonvilliers’ fascia separates the rectum from the prostate and bladder. Stripping of this fascia results in troublesome bleeding from prostatic venous plexus.
• The rectum is attached to the side wall of the pelvis by lateral ligaments, which contain middle haemorrhoidal vessels. These need ligation or coagulation during mobilisation of lower rectum.
• Valves of Houston: Despite the name rectum means straight, it is never straight in adults. It has one convexity on the left and two convexities on the right side. There are 3 valves of Houston (prominent mucosal folds), two on the left and one on the right.
• That portion of the rectum resting on the pelvic floor is called ampulla—the dilated portion of the mid-rectum. Rectovesical pouch

Rectovesical Pouch Or rectouterine Pouch:

• After investing the upper rectum, pelvic peritoneum is reflected anteriorly in males onto the urinary bladder, thus forming into rectovesical pouch. In females, it reflects onto uterus to form rectouterine pouch.
• It is one of the sites of transcoelomic spread of malignant cells.
• Malignant cells settle down in this most dependent part of the abdominal cavity and grow.
• They are palpable by rectal examination, a shelf-like finding—popularly called Blumer’s shelf.
• Thus, if per rectal or per vaginal examination findings suggest the presence of Blumer’s shelf—it means hard deposits are felt and the case is inoperable.
• Rectovesical pouch is also the site of pelvic abscess.
• Pelvic abscess is diagnosed by per rectal or per vaginal examination.
• Pus can be drained through the rectum or posterior fornix.
• Aspiration of blood from rectovesical pouch through the posterior fornix indicates intraperitoneal bleeding may be ruptured ectopic

Arterial Supply

1. Superior haemorrhoidal artery: The superior haemorrhoidal artery  is a branch of the superior rectal artery which is the continuation of the inferior mesenteric artery. It divides into right and left branches. The right branch divides into anterior and posterior branches which supply the rectum.
2. Middle haemorrhoidal artery:  A branch of internal iliac artery, runs in the lateral ligament of the rectum.
3. Inferior haemorrhoidal artery: A branch of internal pudendal artery, supplies the lower rectum.

Venous Return

The rich submucous plexus of veins surrounding the ampulla forms the external rectal plexus.

The venous drainage from here flows in two directions:

1. Upwards: Upwards to drain into superior rectal veins. These join inferior mesenteric veins, which in turn drain into the portal system.
2. Across: Across to drain into middle rectal veins, which run in the lateral ligament of the rectum along with the middle rectal artery. Hence, the lateral ligaments have to be ligated and divided during resection of rectum. These veins drain into internal iliac veins (systemic circulation). Hence, rectum is a site of portosystemic anastomosis.

Lymphatic Drainage of Rectum

1. Upper one-third of rectum is completely enclosed by peritoneum and the middle one-third of rectum is covered in front and on the sides by the peritoneum. From these areas, lymphatic drainage always occurs in the upward direction, first to (1) pararectal nodes of Gerota followed by superior haemorrhoidal nodes, middle haemorrhoidal nodes and nodes at the origin of inferior mesenteric artery.
2. From lower one-third of the rectum, lymphatics spread in the lateral direction and can involve (2) internal iliac nodes.
3. Lymph nodes are also present in the hollow of the sacrum along the median sacral artery (3). Lymphatics are present in the muscularis mucosa.

Nerve Supply

• Sympathetic: The fibres come from the hypogastric plexus, which is located at the aortic bifurcation at the level of L5. Injury to this can cause absence of erection or a dry orgasm. Fibres also come along with the inferior mesenteric artery and superior rectal artery.
• Parasympathetic: (S2, S3, S4) by means of nervi originates from the hypogastric plexus and supply motor fibres to the detrusor. Pain and the ability to distinguish flatus and faeces is because of these fibres.
• Loss of the rectal mucosa results in the loss of these sensations. During the division of lateral ligaments or during anterior dissection of the bladder base, injury to nervi originates can occur.
• The external anal sphincter and puborectalis are innervated by inferior rectal branches of the internal pudendal nerve (somatic).

Examination of Rectum and Anal Canal:

These are the common anal/perianal conditions which can be diagnosed by inspection (only), or palpation or per rectal examination/proctoscopic examination

Staging

1. Modified Dukes’ Staging of Carcinoma of Rectum:

Staging Stages:

• Growth confined to the rectal wall
• Growth involving perirectal pad of fat and tissues
• No nodes are involved.
  • B1: Invading muscularis mucosa
  • B2: Invading to or through seros

• Nodes are involved
  • C1: Local lymph nodes—pararectal
  • C2: Distal lymph nodes—along the course of blood vessels
• Distant spread—liver, lungs, etc.

2.  Astler-Coller Modification of Dukes’ System:

Dukes’ System Stages:

• A  – Limited to mucosa—no nodes
• B1 – Extension into muscularis propria—no nodes
• B2 – Extension into entire bowel wall—no nodes
• B3 – Extension into adjacent organs—no nodes
• C1 – Extension into muscularis propria—positive nodes
• C2 B2 + Lymph nodes
• C3 B3 + Lymph nodes
• D Distant metastasis

Prognosis as per Dukes’ Staging:

• Dukes’ A: 5-year survival is 90 to 100%.
• Dukes’ B: 5-year survival is 50 to 80%.
• Dukes’ C: 5-year survival is less than 50%.

3. TNM Staging

• T  – Primary Tumour
• TX- Primary tumour cannot be assessed
• T0 – No evidence of primary tumour
• Tis-  Carcinoma in situ: Intramucosal carcinoma (involvement of lamina propria with no extension through muscularis mucosae)
• T- 1 Tumour invades the submucosa (through the muscularis mucosa but not into the muscularis propria)
• T2 – Tumour invades the muscularis propria
• T3 – Tumour invades through the muscularis propria into pericolorectal tissues
• T4 – Tumour invades the visceral peritoneum or invades or adheres to adjacent organ or structure.
• T4a Tumour invades through the visceral peritoneum (including gross perforation of the bowel through tumour and continuous invasion of tumour through areas of inflammation to the surface of the visceral peritoneum)
• T4b – Tumour directly invades or adheres to adjacent organs or structures
• N –  Regional Lymph Nodes
• NX – Regional lymph nodes cannot be assessed
• N0-  No regional lymph node metastasis
• N1-  One to three regional lymph nodes are positive (tumour in lymph nodes measuring ≥0.2 mm), or any number of tumour deposits are present and all identifiable lymph nodes are negative
• N1a  – One regional lymph node is positive
• N1b –  Two or three regional lymph nodes are positive
• No – regional lymph nodes are positive, but there are tumour deposits in the subserosa, mesentery or non-peritonealized pericolic, or perirectal/mesorectal tissues
• N2 –  Four or more regional lymph nodes are positive
• N2a –  Four to six regional lymph nodes are positive
• N2b – Seven or more regional lymph nodes are positive
• M –  Distant Metastasis
• M0-  No distant metastasis by imaging, etc.; no evidence of tumour in distant sites or organs
• M1 – Metastasis to one or more distant sites or organs or peritoneal metastasis is identified
• M1a – Metastasis to one site or organ is identified without peritoneal metastasis
• M1b-  Metastasis to two or more sites or organs is identified without peritoneal metastasis
• M1c-  Metastasis to the peritoneal surface is identified alone or with other site or organ metastases

T1s: Does not penetrate muscularis mucosa

T1s: Intraepithelial carcinoma—but this term is not used.

pT4a: It should not be used for non-peritonised portion of large bowel such as ascending and descending colon, lower rectum.

Minimum of 12 nodes should be removed. If less number of lymph nodes are removed, even if they are negative, these patients should receive chemotherapy.

M1a: Multiple metastasis in an organ, even paired organs (ovaries lungs) M1a disease

Stage grouping:

Stage 1: T1 or T2 N0 M0, Stage 2A: T3 N0 M0,

Stage 2B: T4 N0 M0, Stage 3A: T1 N2a M0, T3 or T4a N1/N1c M0,

Stage 3B: T2 or T3 N2a M0, T1 or T2 N2b M0, Stage 3C: T3 or T4a N2b M0, T4b N1 or N2 M0,

Stage 4: Any metastasis.

Staging of Carcinoma of Rectum Investigations

1. Proctoscopy:

It should be done in all cases of bleeding per rectum. It is done as an outpatient procedure. The left lateral position with buttocks elevated on a small pillow is the ideal position for proctoscopy. However, the knee-elbow position can also be used. The growth appears as an ulcer with everted edges.  A biopsy is taken to confirm the diagnosis.

The histological grading of the tumour is as follows:

1. Well-differentiated carcinoma: Low-grade variety (10–15%).
2. Moderately differentiated carcinoma: The most common variety (65%).
3. Undifferentiated carcinoma: The most aggressive variety (20–25%

2. Sigmoidoscopy: To take a biopsy from rectosigmoid growths, sigmoidoscopy is essential.

3. Colonoscopy: to detect any synchronous carcinoma. it can be present in about 8 to 10% of patients. it can also detect adenomas, and polyps. biopsy should be taken in all suspicious lesions.

4. CEA: Increased levels of carcinoembryonic antigen indicate metastasis.

5. Ultrasound of the abdomen: It is done to know the metastasis such as secondaries in the liver, ascites with para-aortic nodes, etc. Colloid carcinoma rectum is one of the types which can present as metastasis.

6. Endorectal ultrasonography (EUS) Endoscopic ultrasound staging of rectal tumours:

• UT1 Invasion confined to the mucosa and submucosa
• UT2 Penetration of the muscularis propria but not
• through the mesorectal fat
• UT3 Invasion into the perirectal fat
• UT4 Invasion into the adjacent organ
• UN0 No enlargement of lymph nodes
• UN1 Perirectal lymph nodes enlarged

EUS:

• It is also called Trans Rectal Ultra Sonography (TRUS)
• To know the level of penetration
• Detect perirectal lymph node enlargement
• Invasion of adjacent structures—levator ani, bony pelvis, etc.
• It is superior in T-staging of rectal cancers.

7. CECT scan: Contrast enhanced computed tomography

• It helps to detect the lesion, to know the extension of the tumour thus able to detect T staging.
• To know the fixation to adjacent structures (ureter, uterus, bladder base, etc. hydronephrosis).
• Importantly, to know nodal status
• Detect metastasis in liver.

8. MRI:

• Both MRI and EUS are good for assessment of
• T-staging. MRI has the following advantages
• It is better for T3 and T4 stages.

Importance of each investigation and how it alters the treatment plan in a case of biopsy-proven carcinoma rectum. APR—abdominoperineal resection, HAR, LAR—high and low anterior resection

• High-resolution MRI is better for assessment of circumferential resected margin (CRM).
• It is also good for lymph nodal staging and phased array MRI can pick up small nodes.

Rectum And Anal Canal Treatment Principles

1. Aim is to have a curative resection.
2. Palliative resection is worth doing even in the presence of metastasis, when there is obstruction.
3. Even though surgical treatment is the main modality, radiotherapy and chemotherapy are beneficial.
4. At surgery, ligation of vascular pedicle is done first to prevent tumour embolisation.
5. Ligation of bowel, proximal and distal to the tumour helps to prevent transluminal dissemination.
6. Distal surgical margin should be about 2 cm.
7. Proximal margin—minimum 5 cm.
8. Radical surgery is described as total mesorectal excision (TME)—which improves quality of lif
9. A double-stapled anastomosis as described or a handsewn anastomosis is then performed. A diverting loop ileostomy is used routinely for these ultra low anastomoses.

Total Mesorectal Excision—Advantages

1. The mesorectum is the perirectal fat surrounding the rectum.
2. It preserves autonomic nerves
3. Impotence, urinary incontinence and retrograde ejaculation are lesser after TME
4. High-resolution MRI is better for assessment of circumferential resected margin (CRM).

Ten Commandments Of Total Mesorectal Excision:

1. Should perform TME in all cases of mid and lower carcinoma rectum
2. Should excise the entire mesorectum (contains fat, lymph nodes and superior rectal blood vessels)
3.  Should perform the dissection with electrocautery or scissors
4.  Should open the posterior plane between visceral and parietal layers of endopelvic fascia—holy plane of Heald or avascular plane
5. Should exert good traction and counteraction to develop the planes
6. Should excise the entire mesorectum circumferentially—minimum of 5 cm of the CRM
7. Should be inside the pelvic plexus laterally
8. Should excise Denonvilliers’ fascia anteriorly
9. Should excise rectosacral ligament so as to reach the pelvic floor
10. Should perform proximal diversion ileostomy

Colonic pouch:

• The splenic flexure is mobilised first. A 6 cm limb of sigmoid or descending colon is folded and a pouch is created. A colotomy is made at the apex of the pouch.
• Linear cutter is used to staple the pouch on itself to create a common lumen.
• A second fire of the stapler may be necessary. This pouch now acts like a neorectum.

Laparoscopic Mesorectal Excision

Laparoscopic Mesorectal Excision Introduction

Laparoscopic anterior resection and total mesorectal excision are well-established procedures now. It is possible because of advances in the laparoscopic instruments, high definition cameras and improved technology.

Laparoscopic Mesorectal Excision Advantages

• A 30° camera allows a beautiful magnified view of the entire dissecting field specially low down in the pelvis. Thus, no part of the laparoscopic procedure is blind.
• Laparoscopic surgery allows the surgeon to adopt the principle of no touch technique. At the same timewith better visualisation of the rectum and mesorectum all around, it permits a good dissection.
• It is not uncommon in the open method that the specimen gets torn due to traction. It has been proved that this tearing is much less in laparoscopy.
• Recovery is very fast after laparoscopy.
• Better preservation of the pelvic autonomic nerves,low anastomotic leak and low mortality rates.
• For laparoscopic low resections, one needs not mobilise splenic flexure but sigmoid can be used for anastomosis.

Laparoscopic Mesorectal Excision Disadvantages

1. Very low resection: Because of the limited space and the lack of proper curved instruments—the open method has a slight advantage.
2. Port site recurrence: Local tissue trauma due to trocars, tumour manipulation, tumour behaviour are the factors responsible for port site recurrence.
3. Tumour spillage, tumour cell aerosolisation due to sudden loss of pneumoperitoneum, tumour spillage during extraction and immunosuppression during pneumoperitoneum are a few factors responsible for port site recurrence. This can be minimised by using bag for extraction, minimal handling of the tumour and avoiding tearing of the specimen.

Different Types Of Surgeries For Carcinoma Rectum

Carcinoma Upper One-third of Rectum

• High anterior resection, which includes removal of growth along with the nodes, followed by colorectal anastomosis is the treatment of choice. This is the operation of choice when the growth is situated between 11 and 15 cm from the anal verge. The lymphatic spread from upper one-third is always in the upward direction.
• Hence, the sphincter is saved. If the bowel is well prepared, protective colostomy is not necessary (sphinctersaving surgery).
• Stapler anastomosis is popular as there is a lesser incidence of leak.

Carcinoma Lower One-third of Rectum

This refers to growth within 4 cm from the anal verge.Two types of surgery can be done depending upon the degree of involvement of the growth with adjacent and surrounding tissues.

When the sphincter is involved, abdominoperineal resection (APR) is done. In early cases, local excision can be done. In patients with low rectal cancers—T3 and T4 lesions, chemoradiation is given before surgery. This method is also followed when sphincter is involved. This is called preoperative chemotherapy. Inoperable lesions may become operable, and, in a few patients, it is possible to save the sphincter. Details are given later.

1. Radical surgery:

Radical surgery is called abdominoperineal resection (APR) or Miles-Walker operation. The patient is put in Lloyd-Davies position (supine with lithotomy). Two surgeons operate simultaneously, one from the abdomen and one from the perineum. Abdomen is opened first and the growth is mobilised from the sacrum and urinary bladder.

At this stage, anus is closed by a perineal surgeon. Rectum and anal canal are mobilised. The entire specimen of rectum, anal canal and lymph nodes are removed followed by permanent endcolostomy by bringing the sigmoid colon outside in the left iliac fossa (sphincter sacrificing surgery).

Structures Removed in APR:

• Growth with entire rectum and anal canal.
• Fascia propria with pararectal nodes.
• Two-thirds of the sigmoid colon and mesocolon with lymphatics and lymph nodes.
• Muscles and peritoneum of pelvic floor.
• Wide area of perianal skin, with part of ischiorectal fossa.

2. Local excision: In our country, 95% of low rectal cancers are offered and treated with  abdominoperineal resection. Very small percentage of patients may be considered for local treatmen —local excision. This can be done only in selected group of patients.

Local Excision of Carcinoma Rectum

• Mobile tumours less than 4 cm in diameter
• Less than 40% of rectal wall involvement
• Located within 6 cm of anal verge
• Lesion should be T1 or T2 with node-negative status
• No vascular or lymphatic invasion
• No nodal involvement—preoperative MRI or EUS.
• Well/moderately differentiated

Various Photographs of Carcinoma Rectum At Surgery 

3. Ultra-low resection: Low anterior resection and ultralow resection

• In female pelvis, broad pelvis, and even in thin males, a tumour measured at 5 cm by rigid proctoscopy, at surgery often may be moved to 8 cm from the dentate line, thus growth can be resected with a good margin and low resection can be done.
• Now with availability of the staplers, if one can give a 2 cm distal margin, ultra-low resection can be done followed by stapler anastomosis.
• Stapler anastomosis is the choice for low and ultralow resections. A 30-, 45-, or 60-mm linear stapler is used. The bowel is clamped and transected just proximal to this point
• A diverting loop ileostomy is done in any low anastomoses (<5 cm) from the dentate line, which are associated with anastomotic leak rates of up to 17%. Other risk factors for anastomotic leak include a history of radiation, malnutrition, elderly patients undergoing preoperative combinedmodality therapy with planned postoperative chemotherapy
• Coloanal anastomosis is done just above the anorectal ring. It usually causes increased frequency of stool, incontinence or soilage, and impaired quality of life owing to an insufficient reservoir. Diet restrictions and time after surgery usually will improve these symptoms.These complications can be minimised by creating a colonic pouch.

Recent change in APR:

In the conventional APR, dissection is within the levator ani and the levator ani is preserved. The change is APR with the removal of levator ani—it is called Extra Levator Abdominoperineal Excision (ELAPE). The resected specimen has a waist—it is called cylindrical APR. Aim is to get adequate CRM.

Carcinoma Middle One-third of Rectum

• This refers to growth between 7 and 11 cm from the anal verge. The decision to save the sphincter can be taken at laparotomy. In cases of well-differentiated carcinoma, a 2 cm margin is adequate. In anaplastic carcinoma, 5 cm clearance is necessary.
• In female patients with broad pelvis after mobilisation of the rectum, the 7 cm growth may appear around 10 cm from the anal verge. Thus, the sphincter can be saved. If the sphincter can be preserved, low anterior resection (LAR) should be done. (APR is also done, if the tumour is bulky and highgrade.

Inoperable Cases: Locally advanced growths present with severe pain, bleeding and with subacute intestinal obstruction. Temporary loop colostomy is done in the left iliac fossa by bringing the sigmoid colon outside. Postoperatively, radiation and chemotherapy are given.

Hartmann’s Operation: This is indicated in old and debilitated patients who may not withstand APR. The rectum is excised, the lower end of the rectum is closed and a colostomy is performed. When the growth is slow-growing, this operation gives good palliation.

Other Types of Surgeries: Tem (transanal endoscopic microsurgery): It involves wide anorectal retraction, followed by good visualisation of lesion using an operating sigmoidoscope and distension of rectum by CO2 followed by complete thickness excision and direct suturing. It can also be done by trans-sacral or trans-sphincteric approach.

Endoscopic Treatment Of Colorectal Lesions

1. Colonoscopic polypectomy: All adenomas and potential adenomas should be removed. Pedunculated polyps are removed by snare. Small polyps can be removed by cold or hot forceps and hot or cold snare. Bleeding can be controlled by injection of epinephrine, electrocautery, clips or endoloops.

2. Endoscopic mucosal resection: It is indicated for flat, sessile lesions, not more than 2.5 cm in diameter. First the lesion is elevated by injecting saline or hypertonic dextrose with epinephrine. The lesion is elevated, cut and removed or sucked and cut.

3. Endoscopic submucosal dissection: Technically more difficult. Principle of the procedure is same. More chances of perforation

4. Endoscopic stents for decompression for malignant obstruction:

• Large-bore colorectal decompression tubes are available. They can be passed with or without endoscope with a guidewire. They are used to relieve obstruction so that bowel preparation can be done and one-stage treatment—resection and anastomosis can be done.
• Self-expandable metal stents—SEMS have been used as palliation in cases of large gut obstruction. Quality of life is slightly better but no increase in the survival rate of patients. Stent migration, tumour ingrowth, overgrowth, perforation and bleeding are the other complications.

5. Bridge to surgery: In left colonic obstruction, this is used in operable and advanced lesions. Selfexpandable metal stents—SEMS is used to relieve obstruction or an emergency ostomy without resection.

Advantages of this method is:

• Get time for correction of fluid/electrolyte imbalance, normalization of bowel caliber, mechanical bowel preparation, provides time for the multidisciplinary team to complete staging workup. We can also screen for synchronous lesions, and initiate neoadjuvant therapy for the primary tumour, if needed.
• Advantage of diverting ostomy being, it offers a high success rate for relieving obstruction compared to stenting, no need for tumor manipulation, no potential risk of stent-related perforation or tumor spillage.

Role Of Radiotherapy And Chemotherapy

Postoperative Management

•  pT1-2N0M0 do not require any adjuvant treatment, such patients can be kept on follow-up with routine 3 monthly CEA and annual CECT thorax/abdomen/ pelvis.
• pT3N0M0 or node positive disease requires adjuvant treatment in the form of concurrent chemoradiotherapy and chemotherapy. Example: 2 cycles of
• FOLFOX (5-FU + Leucovorin + Oxaliplatin) → concurrent 5-FU/Leucovorin and radiation → 2 more cycles of FOLFOX. Oral Capecitabine can be used in place of IV 5-FU.
• It is preferable to add Oxaliplatin in the chemotherapy regimen, if nodes were positive for metastatic disease. Although in older population (>65–70 years), it might be of less benefit.
• Radiation portals should include the postoperative tumour bed, presacral nodes and internal iliac nodes.
• External iliac nodes should be included in T4 tumours. Radiation dose is usually 45–50 Gy given over 5 days a week for 5 consecutive weeks. Another 5–9 Gy boost to the tumour bed can be considered especially when there are adverse features such as lymphatic emboli, close margins, etc

Preoperative—Neoadjuvant Chemoradiation

Rationale: In locally advanced cases where the surgeon feels that complete resection may not be feasible or sphincter saving will not be possible, neoadjuvant chemoradiation can be attempted thus saving the patient from having a permanent colostomy bag and also better curative outcomes

Advantages of Preoperative Radiotherapy

• Decreased tumour seeding at surgery
• Increased radiosensitivity due to more oxygenated cells
• Conversion of APR to LAR

Generally, clinically T3–T4 tumors which may or may not be node positive are eligible candidates for neoadjuvant (NACT) chemotherapy.

•  A typical course of NACT comprises concurrent 5-FU/Capecitabine and radiation. A dose of 45– 50 Gy is used to treat the pelvis including the growth and the draining lymphatic regions followed by 5 Gy boost to the tumors itself.
•  Following NACT, the patient should be re-evaluated using CT/MRI for the possibility of resection.
• Surgery is usually considered after 6–8 weeks of
• NACT as the maximal response to the treatment may take up to 2 months.
•  Further adjuvant treatment is to be given following surgery depending upon the histopathological report.

Locally Recurrent Rectal Cancer

Major cause is a positive margin on the pelvic side wall. This is the reason why preoperative chemoradiotherapy should precede excision of T3 and T4 lesions with TME.

• Usually develops within 18 months.
• Presents as pelvic pain, mass and rectal bleeding.
• Pelvic CT, MRI, CEA levels are the required investigations.
• Chemoradiation, surgery, local palliative treatment, and pelvic exenteration (resection of rectum and bladder—Brunschwig’s operation) are alternative treatments availabl

 

Prolapse Rectum

Protrusion of the mucous membrane or the entire rectum outside the anal verge. This condition is common in children and elderly patients.

Prolapse Rectum Types: Prolapse can be of two types:

1. Partial prolapse and
2. Complete prolapse

Partial Prolapse

• In this variety, the protrusion is between 1.25 and
• 3.75 cm outside the anal verge
• It is usually a mucosal prolapse.

Prolapse Rectum Causes

•  In infants, it is due to undeveloped sacral curve and in children it can be secondary to habitual constipation.
•  It can follow an attack of whooping cough or excessive straining.
• It can follow an attack of diarrhoea resulting in loss of fat in the ischiorectal fossae, which supports the rectum.
• In adults, it is common in females mostly due to torn perineum caused by obstetric trauma.

Prolapse RectumTreatment

• Digital reposition: In infants, partial prolapse is temporary. The mother is advised to push the prolapse inside after lubricating with lignocaine jelly

• Injection of ethanolamine oleate into the submucosa of the rectum. It causes aseptic fibrosis. Thus, mucosa gets tethered to the other layers.
• Partial prolapse can be excised, after applying Goodsall’s ligature.

Complete/Total Prolapse

• Full-thickness prolapse is also called procidentia.
• It is defined as protrusion of the rectum for more than
• 3.75 cm outside the anal verge. Very often, it is the entire rectum which protrudes out on straining, sometimes along with the peritoneal sac.
• Often, it is associated with a prolapse uterus.

The Pelvic Floor—Surgical Anatomy

• It is composed of two levator ani and a puborectalis muscle.
• Levator ani originates from the pelvic side walls and sacrospinous ligament. It suspends the rectum in a muscular sling till the level of puborectalis.
• Puborectalis muscle takes origin from posterior aspect of pubis, forms a sling around rectum and returns to posterior pubis.
• Contracted puborectalis is responsible for normal acute anorectal angle and it is critical for maintaining continence. Thus during coughing and sneezing, anorect angle becomes more acute, increasing continence.

Supports of the Rectum and Surgical Importance:

Various supports keep the rectum in place. Failure of one or more of these factors may precipitate rectal prolapse.

They have been enumerated as follows:

1. Pelvic floor: Weakness of pelvic floor can be due to birth injuries or due to defective collagen maturation.
2. Lateral ligaments: These ligaments are either condensation of pelvic fascia on either side of the rectum. Excessive mobility of these ligaments may be the contributing factor for prolapse rectum.
3. Fascia of Denonvilliers (rectovesical fascia): Deep rectovesical pouch is often found in the prolapse rectum. In all cases of complete prolapse rectum, please look for the deep rectovesical pouch and if present, it should be obliterated.
4. Fat in the ischiorectal fossae supports the rectum: Hence, any chronic illness and loss of fat may contribute to prolapse rectum.

Photographs Of Prolapse Rectum

Anorectal Physiology and Investigation

These are useful in patients who have complaints of prolapse rectum, constipation, and incontinence.

1. Anorectal manometry:

• Normal resting pressure in the anal canal—40– 80 mmHg. (It is the function of internal anal sphincter.)
• Squeeze pressure: It is maximum voluntary contraction pressure minus resting pressure. It is 40–80 mmHg above resting pressure.
• It reflects the function of external anal sphincter.

2. Function of pudendal nerve and perineal nerve: Injuries to the nerve are diagnosed by nerve conduction studies.

Photographs Of Prolapse Rectum Causes or Pathogenesis:

• Common in elderly women who are multipara. It is probably due to repeated birth injuries to the perineum causing damage to the nerve fibres. As age advances, muscles become weak. This, together with fatty degeneration of the muscle, results in prolapse rectum.
•  Excessive straining causes weakness of the supports of the rectum.
• Defective collagen maturation results in failure of rectal support by elevators and pelvic fascia.

Obstetric Trauma:

• Multiple vaginal deliveries—cause pudendal nerve stretch.
• Prolonged labour—disrupts sphincter and stretching of pudendal nerve.
• 3rd-degree perineal tears—weaken the internal sphincter and pelvic floor

4. The presence of a deep rectovesical pouch and excessive mobility of the rectum (mesorectum) predisposes to prolapse of the rectum.

5. Many people believe that prolapse of the rectum starts as an intussusception in the first stage, initiated by certain factors such as diarrhoea, constipation and disorder of the pelvic floor. The process starts with the anterior wall of the rectum, where supporting tissues are weakest (Broden–Snellman theory).

Beahrs Classification

1.  Incomplete—mucosal prolapse
2.  Complete—full-thickness rectal prolapse
   • 1st degree—concealed
   • 2nd degree—externally visible on straining
   • 3rd degree—visible without straining

Photographs Of Prolapse Rectum  Clinical Features

• Female-male ratio is 6:1.
• Constipation is an important feature of rectal prolapse.
• Excessive mucus discharge irritates the perianal skin. Tenesmus is also common.
• On asking the patient to strain at stool,1 the rectum descends down, which clinches the diagnosis
• Some degree of incontinence of faeces and flatus is always present. It gives rise to urgency and perianal soiling.
• Rectal examination—lax anal sphincter and wide gaping on straining.
• Procidentia
• Recurrent attacks of prolapse and negligence in seeking medical attention can give rise to gangrene.
• Such patients may require proctosigmoidectomy.

Photographs Of Prolapse Rectum Differential Diagnosis

• Large third-degree haemorrhoids—not circumferential and are blue.
• Large polypoid tumour
• Prolapse of sigmoid colon

Photographs Of Prolapse Rectum Complications

• Proctitis, ulceration and rarely bleeding
• Gangrene of the rectum

Photographs Of Prolapse Rectum Treatment

• Medical management—prior to surgery, patients not fit for surgery or patients who refuse surgery
• Adequate fluid and fibre intake
• Enemas and suppositories for severe constipation

Surgical Procedures—Aim

1. Safe procedure to correct with minimal morbidity and without mortality. They are classified as perineal procedures and abdominal procedures.
2. To cure or to improve incontinence.

Perineal Procedures (Preferred for High-Risk Patients)

1. Delorme’s procedure (reefing the rectal mucosa):

• In this, the prolapse is completely everted, the mucosa is stripped and the muscle coat is plicated.
• Mucosal continuity is maintained by suturing the anal canal mucosa below to the rectal mucosa above. This is an easy operation to do in elderly patients.
• However, relapse rates are high and it does not correct the defect.

2. Altemeier’s procedure:

• In this operation, the full thickness of the prolapsed rectum with part of the sigmoid is excised followed by anastomosis of part of the sigmoid to the anal canal from below.
• To improve continence, plication of levator ani and puborectalis muscle is done. Urgency and incontinence are the features because of the removal of the rectum

3. Thiersch wiring:

• In this operation, a steel wire or a thick silk suture is applied all around the anus after reducing the prolapse.
• The knot is tightened around a finger. Patients with poor surgical compliance benefit from this operation. However, breakdown of the wire, perianal sepsis and anal stenosis are the complications.

Abdominal Procedure—Mesh Rectopexy— Laparoscopic Or Open Method

A marlex mesh or prolene mesh can be kept behind the rectum. This is sutured behind, to the sacrum and then to the posterior and lateral surfaces of the rectum. The laparoscopic method of fixing the mesh has become popular. This is the procedure of choice today. Constipation is one of the complications of mesh rectopexy

Summary of Surgeries for Prolapse Rectum:

• Mesh rectopexy corrects/prevents prolapse but does not correct chronic constipation.
• Laparoscopic mesh rectopexy has become the gold standard—fast recovery, less pain, short hospital stay.
• Mesh rectopexy with resection is ideal for patients with constipation or patients with a redundant sigmoid colon.
• High operative risk patients—Thiersch wiring—anal encirclement.
• Altemeier procedure done for the perineum is an alternative in patients with incontinence. Here, perineal proctectomy and posterior sphincter enhancement is done

Surgical Anatomy of Anal Canal

The anal canal is 3 cm long, starts as the continuation of the rectum, passes through pelvic diaphragm and ends at the anal verge (skin).

Internal Anal Sphincter (IAS) 

• It is the continuation of circular muscle fibres of the rectum and ends 0.5 cm below the pectinate line.
• It is involuntary and 2.5 cm long.
• The IAS is a muscular ring that surrounds about 2.5–4.0 cm of the anal canal. Its inferior border is in contact with, but quite separate from, the sphincter ani externus muscle.
• Internal sphincter with fibres of external sphincter and puborectalis which maintains the anorectal angle, form the anorectal bundle, and maintains continence.

• Its fibres are transversely placed. Motor fibres come from presacral plexus.

External Sphincter

• It is formed by striated muscle fibres intermingled with longitudinal muscle fibres of the rectum which are attached to the skin of perianal region.
• It has superficial, deep and subcutaneous portions.
• The funnel-shaped configuration of the paired levator ani muscles form the major part of the pelvic floor, and their fibers decussate medially with the contralateral side to fuse with the perineal body around the prostate or vagina.
• Nerve supply (motor) comes from an inferior haemorrhoidal branch of the internal pudendal nerve and the perianal branch of the 4th sacral nerve (motor to levator ani also).
• It is voluntary and gives temporary continence.

Development

• The anal canal is developed from the fusion of the post-allantoic gut with the proctodeum.
• The junction of these is the dentate line or pectinate line. Anal valves of Ball are remnants of proctodeal membrane.
• At the level of the dentate line, the mucosa is folded in the form of longitudinal columns—columns of Morgagni.
• In between the columns of Morgagni, 4–8 anal glands open into small anal sinuses.

Lining Epithelium

• The mucosa of the upper anal canal, like that of the rectum, is pinkish and is lined by columnar epithelium, whereas the mucosa distal to the dentate line is paler and lined by squamous epithelium devoid of hair and glands.
• The change between the two types of epithelium is called transitional zone. It lies immediately proximal to the dentate line and consists of layers of cuboidal cells with a few columnar cells.
• Thus diseases affecting the rectal mucosa, such as ulcerative colitis, can extend to the transitional zone but not distal to the dentate line. Cancers proximal to the dentate are typically adenocarcinomas, and those distal are squamous cell carcinoma.
• Thus even after total proctocolectomy and pouch procedures for ulcerative colitis, carcinoma can occur in the transitional zone.
• At the anal verge, characteristics of normal skin with its apocrine glands are present. This is where infectious complications of the apocrine glands—hidradenitis suppurativa can occur. This differentiation helps in sensory perception, which influences the surgical approaches to anorectal conditions.
• To give an example, internal haemorrhoids can be treated with rubber band ligation without the need for local anaesthesia. On the other hand, the excision of external hemorrhoids requires the application of local anaesthesia.

Blood Supply, Lymphatic Drainage and Nerve Supply

• The superior portion of the anal canal (i.e. superior to the dentate line) is supplied by the superior haemorrhoidal artery. Below the dentate line, the inferior haemorrhoidal arteries supply the inferior most part of the anal canal. Between the two, the middle haemorrhoidal arteries form anastomoses.
• Above the dentate line, internal haemorrhoidal venous plexus drains into the superior haemorrhoidal vein. Below, veins drain into the inferior haemorrhoidal vein. Also, middle haemorrhoidal veins drain the muscularis externa and anastomose with the superior and inferior haemorrhoidal veins.
• The lymphatic drainage: Above the dentate line, the lymphatics drain into the internal iliac lymph nodes and below the dentate line, lymphatics drain into the superficial inguinal lymph nodes.
• Nerve supply: The anal canal has differing nervous innervations above and below the dentate line. Above the dentate line, the nerve supply comes from the inferior hypogastric plexus (visceral).
• This part of the anal canal is sensitive to stretch.
  • Below the dentate line, the nerve supply is somatic, receiving its supply from the inferior haemorrhoidal nerves (branches of the pudendal nerve). It is sensitive to pain, temperature, and touch.

Anorectal Physiology

• The anal canal which has length of 4 cm, lengthens with squeezing of the external sphincter and shortens
• With straining during defaecation. Resting pressure, which depends largely on the internal sphincter, averages 90 cm H₂O. It is lower in women and older patients than in men and younger patients.
• This high-pressure zone increases resistance to the passage of stool. The external anal sphincter and puborectalis muscle generate pressure, by contraction which is more than double the intra-anal canal resting pressure.
• The principal mechanism that provides continence is the pressure differential between the rectum (6 cm H₂O) and the anal canal (90 cm H₂O). The anorectal angle is produced by the anterior pull of the puborectalis muscle as it encircles the rectum at the anorectal ring.
• This angle may act as a flap valve or have a sphincterlike function.
• Anorectal sensation allows discrimination of the enteric contents (gas, liquids, or solids). It also detects the need to pass stools or flatus.
• The internal sphincter will relax when enteric contents reach the anal canal, while the rectum distends and contracts. It is called rectal anal inhibitory reflex.
• Transient relaxation of the internal anal sphincter brings the rectal content into contact with the sensory mucosa of the proximal anal so that it can be recognized.

Mechanism of Anal Continence

• Distension of the rectum causes tonic contraction of the external sphincter, which is controlled by the cerebrum. The centre is in the lumbosacral region of the spinal cord.
• Faeces in the anal canal stimulates the nerve endings.
• Nerve endings are also present in the puborectalis.
• High pressure in the anal canal (25–120 mmHg) and the angle between the rectum and anal canal (80°) are the important factors which maintain anal continence.

Comparision of anal canal above and below the dentate line

Anorectal Abscess

Acute Anorectal Suppuration—Anorectal Abscess

• More common in men especially diabetic. Bloodborne infection is common in diabetic patients.
• Mostly originate from the anal gland opening at the base of the anal crypts. This is cryptoglandular theory of intersphincteric anal gland infection described by Sir Allan Parks.
• From here, pus spreads along path of least resistance—thus form perianal abscess or ischiorectal abscess.
• Other source of anorectal sepsis is a foreign body, trauma, sexually transmitted diseases for lower level abscesses.
• Crohn’s disease and carcinoma rectum with perforation may form pelvirectal abscess (supralevator)
• Typically patients present with high grade fever with chills and rigors. On examination, a tender indurated swelling is found in the perianal region or in the ischiorectal fossa.
• Culture usually shows E. coli in about 70–80% of cases.
• Staphylococcus aureus, Streptococcus, and Bacteroides are the other organisms.

Anorectal Abscess Causes 

• Infection
• Irritation (Crohn’s disease, ulcerative colitis)
• Immunity low (diabetes, AIDS

Anorectal AbscessTypes

1. Perianal Abscess:

• It occurs due to infection of anal glands in the perianal region.
• It may be due to a boil, anal gland infection or thrombosed external pile.
• It produces severe pain, throbbing in nature and on examination, a soft, tender, warm swelling is found.
• Rectal examination reveals a tender, boggy, swelling under the anal mucosa

Anorectal Abscess Treatment: Antibiotics, incision and drainage and excision of part of the skin (roof).

2. Submucous Abscess:

• Collection of pus under the mucous membrane of the rectum or anal canal.
• It can also be due to infection of injected haemorrhoids. It can be drained using a proctoscope.

3. Ischiorectal Abscess

• Collection of pus in the ischiorectal fossa, which is lateral to the rectum and medial to the pelvic wall.
• Bounded above by levator ani and inferiorly by pad of fat in the ischiorectal fossa.
• Ischiorectal fat is poorly vascularised. Hence, it is more vulnerable to infection.
• An abscess occurs due to the spread of perianal abscess or due to blood-borne infection.
• Diabetes is the precipitating factor.

Anorectal Abscess Clinical Features:

• Severe throbbing pain is characteristic of the ischiorectal abscess.
• Induration in the ischiorectal fossa
• Common in diabetic men
• Frank evidence of abscess such as fluctuation need not be seen and is a late sign.
• High grade fever with chills and rigors.
• Per rectal examination is painful and bogginess can be appreciated on the side of the lesion

Deep Abscess without Fluctuation:

• Ischiorectal abscess
• Breast abscess
• Parotid abscess
• Prostatic abscess
• Midpalmar abscess

Treatment

• Under anaesthesia, a cruciate incision (+) is made and the 4 flaps are raised. All the pus is evacuated and the wound is packed with iodine roller gauze and left open.
• Edges of the skin are trimmed to leave an opening so that drainage of pus occurs freely. It heals with granulation tissue within 10–15 days. Appropriate antibiotics are given for a period of 5 to 10 days.

4. Pelvirectal Abscess

It is a pelvic abscess, which is drained through the rectum. The common causes are pelvic peritonitis, appendicitis, septic abortions, etc. The details of the

Anorectal Abscess:

• Common causes such as boil or infected sebaceous cyst has to be ruled out first.
• Remember other causes such as infection following haemorrhoidal injection or band ligation.
• Uncommon causes such as foreign body or penetrating trauma also can give rise to anorectal abscess.
• Last but not least, AIDS and diabetes have to be ruled out in all cases of anorectal abscess causes, clinical features and the management are discussed on See Key Box 49.18 for summary of anorectal abscess.

Pilonidal Sinus (Jeep-Bottom)

• Pilonidal sinus means nest of hairs in Greek. Also called Jeep-bottom because it was very common in jeep drivers.
• More common in dark people than fair people.
• It is an acquired condition, commonly found in hairy males
• It is acquired due to the following reasons:
  • Appears between the age of 20 and 30 years.
  • Hairy men are more affected.
  • The hair follicle is never demonstrated in the wall of the pilonidal sinus but hair is the content of the pilonidal sinus.
• Hair accumulates due to vibration and friction causing shedding of the hair. Thus, it accumulates in the gluteal cleft and enters the opening of the sweat glands.
• Pointed end of the dead hair is inside (blind end of the sinus).

Pilonidal sinus Clinical Features

• External opening of the sinus seen just above the anal verge in the midline over the coccyx.
• History of discharge of pus
• History of recurrent abscesses which rupture, discharging pus.
• Can be asymptomatic.

Pilonidal sinus Sites

• Midline over the coccyx
• Umbilicus
• Interdigital in barbers

Pilonidal sinus Diagnosis

Osteomyelitis of the coccyx is the only differential diagnosis for pilonidal sinus. Hence, X-ray of the coccyx should be taken.

Pilonidal sinus Treatment

• Inject methylene blue to demonstrate branches of the sinus followed by excision of the sinus. The patient is positioned prone with buttocks elevated (Jack knife position).
• After excision, there are two methods to treat the wound—open and closed methods

1. Open method: The wound is left open after excision followed by regular packing with iodine or eusol gauze pieces.

• • It may take 3–4 weeks for the healing of the pilonidal sinus. Regular sitz bath is also given.
  • This method carries the least recurrence.

2. Closed method: The wound is closed by ‘z’ plasty.

• • This method carries 10–20% chances of recurrence.
  • Rhomboid flap (Limberg flap) can be raised to close the defect also

Pilonidal Sinus:

• It is acquired condition—popularly called Jeep-bottom
• Common in hairy men
• Multiple sinuses communicating with each other
• They open to the exterior by multiple openings
• The direction of the sinuses is cephaloid
• Recurrent abscesses which rupture are common
• Excision with or without marsupialisation, flap closure or z plasty are the treatment options.
• In spite of adequate surgical procedures, recurrence is common.

3. Karydakis procedure: The primary procedure is to remove all the sinus tracts and their branches till sacral bone. In this operation, a semi-lateral incision is made around the sinuses and flaps are mobilised to excise all the sinuses and their branches. Then tension-free closure is done. Compared to an elliptical incision, this incision and closure have decreased chances of skin necrosis.

4. Bascom’s technique: In this procedure, an incision is given laterally, not in the midline. After raising It is a congenital condition affecting the sacrococcygeal region. Flaps, and wide excision of the infected sinuses and tracts is done followed by closure of the midline openings. The lateral wound is left open (in the conventional operation, the midline wound is left open).

Sacrococcygeal Teratoma

It is a congenital condition affecting the sacrococcygeal region In this region, totipotential cells persist for a longer period compared to the rest of the area. Hence, it is the site of teratomas.

Sacrococcygeal Teratoma Clinical Features

• 20% of the cases are stillborn babies. It is common in a female child.
• Presents as a swelling in the sacrococcygeal region pushing the rectum anteriorly.
• The surface of the swelling ulcerates. Many cystic areas are present in the swelling.
• The swelling is fixed to the sacrum and coccyx from which it is impossible to separate/isolate.

Sacrococcygeal Teratoma Complications

• Ulceration
• Secondary infection
• Haemorrhage
• Teratocarcinomatous change occurs at one year of age.

Sacrococcygel Teratoma Treatment:

• Excision of the teratoma with part of the sacrum and coccyx
• They are not uncommon tumours which present with bleeding per rectum, burning and itching in the anal region.
• The diagnosis is obvious in many cases once buttocks are separated or by digital examination.
• Tissue diagnosis is a must before radical treatment.

Sacrococcygeal Teratoma Types

1. Squamous cell carcinoma:

• Papillomas are the chief predisposing factors. Local excision or APR (abdominoperineal resection) is the treatment with external RT in appropriate cases.
• For sphincter preservation—chemoradiation can be used. It is called Nigri’s regime.

2. Basaloid carcinoma: It is a highly malignant, nonkeratinising, squamous cell carcinoma. Treatment is similar to squamous cell carcinoma.

Anal Intraepithelial Neoplasia (AIN—Bowen’s Disease):

• It is squamous cell carcinoma in situ of the anus.
• It is a precursor to an invasive squamous cell carcinoma.
• It is associated with human papillomavirus types 16 and 18 (HPV 16,18).
• Anoscopy, and biopsy are to be done.
• Dysplasia is an indication of resection/ablation

3. Melanoma:

• Beware of a patient who comes with bilateral groin nodes which are bulky. The patient may be having malignant melanoma of the anal canal— a bluish/blackish ulcer in the anal canal.
• APR is potentially curable in early cases of melanoma. If metastasis is present, the prognosis is poor. So, only local excision is done so as to provide palliation but colostomy is avoided.

4. Adenocarcinoma is rare:

It can occur from the anal glands in pre-existing anal fistula. APR with 5-FU and radiation therapy is indicated

Stricture Of Anal Canal And Rectum

Stricture Of Anal Canal And Rectum Causes

1. Postoperative: Haemorrhoidectomy, pull-through operations, repeated diathermy fulguration of polyps.

2. Irradiation: It occurs one to two years after irradiation.

3. Senile strictures

4. Lymphogranuloma inguinal: A sexually transmitted disease affecting both male and female patients. Initially, pararectal lymph nodes are enlarged followed by the development of multiple rectal strictures.

5. Inflammatory bowel diseases: Both ulcerative colitis and Crohn’s disease result in rectal strictures (5–10%).

6. Rare: Congenital, amoeboma, carcinoid, endometriosis, tuberculosis, CMV colitis.

Stricture Of Anal Canal And Rectum Clinical Features

• Increasing constipation is the characteristic feature of stricture of the rectum. It may be associated with hard stools, bleeding and pain in some cases. Per abdominal examination may reveal loaded colon with scybalous masses. Rectal examination can detect a stricture.
• It is mandatory to rule out carcinoma rectum which is the most common cause of stricture.

Stricture Of Anal Canal And Rectum Treatment

• Regular dilatation may be necessary for the strictures situated low in the rectum and anal canal.
• Intractable strictures need to be resected.
• Treatment of the primary disease.

Anal Incontinence

Mechanism of Anal Continence

• Distension of rectum causes tonic contraction of external sphincter. This is controlled by the cerebrum and the centre is in the lumbosacral region of the spinal cord.
• Faeces in contact with anal canal stimulates the specialised nerve endings. Nerve endings are also present in the puborectalis.
• High pressure in the anal canal (25–120 mmHg) and the angle between the rectum and the anal canal (80°) are the important factors which maintain anal continence.

Anorectal Ring

• It marks the junction between the rectum and the anal canal.
• It is formed by the puborectalis, the highest part of the internal sphincter, the longitudinal muscle and the external part of the sphincter.

Causes of Anal Incontinence

Traumatic: Injury to the anorectum due to sharp penetrating objects occurs due to accidents.

Surgical procedures:

• Damage to the internal and external sphincter can occur due to Lord’s dilatation1, a procedure done for fissure in ano. However, most of it is temporary.
• Division of high fistula in ano may result in incontinence.
• Following pull-through procedures done for anorectal anomalies, Hirschsprung’s disease.
• Haemorrhoidectomy—very large pile masses.
• Extensive small bowel resection
• Rectal excision

3. Mass in the anorectum: Prolapse piles, prolapse rectum and carcinoma rectum may produce temporary incontinence which subsides after surgical procedures.

4. Neurological causes: In females, pudendal nerve neuropathy which occurs due to chronic straining may result in incontinence. Spinal injuries, spina bifida, meningomyelocele are associated with anal incontinence.

5. GI motility increase: Inflammatory bowel diseases irritate bowel and produce temporary incontinence.

Common Causes of Anal Incontinence

1. Trauma
2. Repeated pregnancies
3. Anal surgery
4. Unnatural sex—anal intercourse
5. Megacolon—congenital or acquired
6. Ageing or senility
7. You can remember as TRAUMA

6. Childhood/congenital causes: Anorectal malformations, Hirschsprung’s disease, spina bifida, abnormal behaviour.

7. Miscellaneous: Old age (senility), general debility and faecal impaction, Parkinson’s disease, behavioural problems, etc.

Stricture Of Anal Canal And Rectum Canal Treatment

Temporary incontinence: Reassurance. Perineal exercises to improve the tone of the internal and external sphincter.

 Permanent incontinence:

• A divided sphincter can be reunited, followed by overlapping of the remaining muscles.
• Intersphincteric repair of puborectalis sling and plication of the external sphincter.
• Gracilis muscle can be used to create a new anal sphincter by transposing it followed by electrical stimulation using a pacemaker.
• Using artificial sphincter.

Proctalgia Fugax

• This condition is characterised by attacks of severe cramp-like pain arising in the rectum.
• Anxiety status, straining at stools or ejaculation are a few precipitating factors.
• The pain may be unbearable, and may recur at irregular intervals. It is possibly due to a segmental cramp in the pubococcygeus muscle. The pain usually lasts for a few minutes and subsides (fleeting perianal pain).
• Symptomatic treatment in the form of analgesics is given.

Pruritus Ani

Pruritus Ani Definition: This is intractable itching around the anus.

Pruritus Ani Causes:

Perianal and anal discharge: Anal fissure, fistula in ano, prolapsed piles, polyps, genital warts are a few conditions which render the anus moist.

1. Poor hygiene, lack of cleanliness, excessive sweating and wearing tight and rough underclothing are common causes.
2. Parasitic causes—threadworm
3. Psychoneurosis
4. Allergy, diabetes are the other causes.

Pruritus Ani Treatment

• Hygienic measures
• Prednisolone topical cream 1% with antifungal agent (miconazole nitrate 2%)
• Moisturising cream/lotion
• Antihistamine—promethazine hydrochloride 10–25 mg at night times.

Pruritus Ani—Avoid

• Toilet paper
• Soap
• Too tight underclothing
• Too many ointments
• Local anaesthetic cream

Hidradenitis Suppurativa

Hidradenitis Suppurativa Definition

It is a chronic recurrent suppuration of apocrine glands in the skin resulting in multiple abscesses which rupture causing multiple sinuses.

Hidradenitis Suppurativa Sites: Axilla, groin, back, buttocks and anal regions are common sites.

• Hidradenitis Suppurativa Pathogenesis:
• Occlusion of the gland ducts results in stasis, bacterial proliferation, abscess, rupture. Common organisms are Staphylococcus aureus and anaerobes (somewhat like breast abscesses).
• Anogenital disease is more common in men. Hence, androgens may play a role in this condition.
• Obesity is another contributing factor.

Hidradenitis Suppurativa Clinical Features

• Common after puberty till the age of 40 years
• Typically, it is a folliculitis presenting as multiple boils which are painful.
• Pus formation, rupture and persisting sinuses are common.
• Interestingly, it neither affects the level of dentate line nor the sphincters.

Hidradenitis Suppurativa Differential Diagnosis

All diseases resulting in multiple sinuses in and around the perineum are the differential diagnosis such as Crohn’s disease, tuberculosis, lymphogranuloma venereum, pilonidal sinuses, actinomycosis, etc.

Hidradenitis Suppurativa Treatment

• When in doubt, rule out other causes mentioned above and if necessary, a good biopsy from the sinus tract and from the edge of the sinus.
• General measures such as weight reduction, antibiotics, antiseptic medicated soaps, washing the part with warm saline or water.
• Surgery includes laying open all the openings or wide excision with or without skin (radical excision) and direct closure or skin grafting of flap reconstruction are the other choices.

Miscellaneous

Multiple Choice Questions

Question 1. Splash in the pan is classically described as bleeding from which condition?

1. Carcinoma rectum
2. Fissure in ano
3. Haemorrhoids
4. Polyp

Answer: 3. Haemorrhoids

Question 2. Which of the following are causes of anorectal fistulae in males except:

1. Crohn’s disease
2. Tuberculosis
3. Ulcerative colitis
4. Lymphogranuloma venereum

Answer: 4. Lymphogranuloma venereum

Question 3. Following are true about peritoneal coverings/fascia of the rectum except:

1. Upper one-third is completely covered
2. Middle one-third is covered anterolaterally
3. Lower one-third is covered anteriorly
4. Waldeyer’s fascia separates the rectum from sacrum

Answer:  3. Lower one-third is covered anteriorly

Question 4. About signet ring carcinoma rectum, the following are true except:

1. It is seen in young patients
2. Cells are filled with mucus and the nucleus is displaced
3. It carries bad prognosis
4. Not an indication for chemotherapy

Answer: 4. Not an indication for chemotherapy

Question 5. The following are true for clinical features of carcinoma rectum except:

1. Can give rise to tenesmus
2. Can present as bloody slime
3. Can present as liver secondaries
4. Can cause closed-loop obstruction

Answer: 4. Can cause closed loop obstruction

Question 6. The ideal surgical treatment for growth at 8 cm from the anal verge is:

1. Abdominoperineal resection
2. Abdominosacral resection
3. High anterior resection
4. Total mesorectal excision

Answer: 4. Total mesorectal excision

Question 7. On-table lavage of the intestines for resection and anastomosis can be done via:

1. Enterotomy
2. Colotomy
3. Enema from rectum
4. Appendicular stump

Answer: 4. Appendicular stump

Question 8. Local excision of malignant rectal tumour can be done, if:

1. The tumour is up to 6 cm in size
2. Up to 60% of the rectal wall involvement
3. Lymphatic invasion is accepted
4. Tumour is well differentiated

Answer: 4. Up to 60% of the rectal wall involvement

Question 9. Prolapse rectum is caused by several factors except:

1. Birth injuries to the nerve fibres
2. Defective collagen metabolism
3. It does not start as intussusception
4. Deep rectovesical pouch

Answer: 3. It does not start as intussusception

Question 10. Below the dentate line, squamous epithelium has:

1. No basal cells
2. Hair
3. Sweat glands
4. Pigment forming cells

Answer: 4. Pigment forming cells

Question 11. Above the dentate line, lymphatic drainage goes to:

1. Para-aortic nodes
2. Superficial inguinal lymph nodes
3. Deep inguinal lymph nodes
4. Pudendal lymph nodes

Answer: 1. Para-aortic nodes

Question 12. The following are true for prolapsed piles except:

• The external sphincter grips the pile mass and causes gangrene
• Thrombosis can occur
• Portal pyaemia can be a complication
• Requires hemorrhoidectomy

Answer: 1. External sphincter grips the pile mass and causes gangrene

Question 13. Which one of these precautions must be taken while applying a band for haemorrhoids?

1. Bands are applied in grade 1 pile masses
2. Bands are applied in grade 4 haemorrhoids
3. Bands are applied below the dentate line
4. Bands should not be applied in patients who are taking anticoagulants

Answer: 4. Bands should not be applied in patients who are taking anticoagulants

Question 14. Anal stenosis is a complication of

1. Stapler haemorrhoidopexy
2. Open haemorrhoidectomy
3. Too low application of the band
4. Cryosurgery

Answer: 2. Open haemorrhoidectomy

Question 15. The following are true for injection line treatment of haemorrhoids except

1. It is given perivascular
2. Given above the level of the dentate line
3. It is painful
4. It is given in the submucosal plane

Answer: 3. It is painful

Question 16.  The following are true for stapler haemorrhoidopexy except

1. The recurrence rate is less
2. Less discomfort than open haemorrhoidectomy
3. Anal stenosis is not a complication
4. Ideal for 3rd or 4th-degree haemorrhoids

Answer: 2. Less discomfort than open haemorrhoidectomy

Question 17. In multiple fistula in ano and high fistula, which one of the following should not be done?

1. Biopsy of the track
2. Colostomy
3. Fistulogram
4. Multiple fistulotomy

Answer: 2. Colostomy

Question 18. Majority of the cases of fissure in ano are:

1. Anterior
2. Posterior
3. Anterolateral
4. Posterolateral

Answer:  4. Posterolateral

Question 19. In lateral sphincterotomy:

1. Pecten fibres are ruptured
2. It is blunt sphincterotomy
3. The external sphincter is divided
4. The internal sphincter is divided

Answer:  4. Internal sphincter is divided

Question 20. In cases of pilonidal sinus:

1. Hair is demonstrated in the wall
2. It is congenital
3. It is known for recurrence
4. It undergoes a malignant change

Answer: 3. It is known for recurrence