Hari ram a 70 year old male presents with h/o lower GI bleed for the last 6 months. Sigmoidoscopic examination shows a mass, of 4 cms about 3.5 cms above the anal verge. The treatment of choice is:
Treatment of rectal cancer: Surgical and oncological management varies greatly depending on the stage of the tumor within the rectum. Superficially invasive, small cancers may be managed effectively with local excision. However, most patients have more deeply invasive tumors that require major surgery, such as low anterior resection or abdominoperineal resection. Low anterior resection: This is a sphincter saving procedure. In this procedure the sigmoid colon and proximal rectum are removed. The descending colon is anastomosed to the distal rectum. Previously this sphincter saving LAR procedure was possible for lesions confined in upper ? rd of rectum. Lesions in lower third were treated with APR with permanent colostomy. With the introduction of stapling gun, the sphincter saving LAR operation can now be done even in lesions of lower ? of rectum, provided a margin of 2 cm or more of normal bowel can be resected below the lesions but above the dentate line. 1 cm of margins can be adequate, provided the carcinoma is well differentiated. Abdominoperineal resection (also known as Miles procedure): In this procedure there is complete excision of the distal sigmoid colon, rectum and anus, by the concomitant dissection through the abdomen and perineum with creation of permanent colostomy. APR is performed when adequate distal margins for LAR cannot be obtained i.e. for carcinoma in lower rectum. Local excision: In carefully selected patients with small, well differentiated, superficial, mobile polypoid lesions, a full thickness excision can be performed through the transrectal route as the definitive therapy. Local excision can be done for selected T1 and T2 lesions without evidence of nodal disease. Palliative procedures: unresectable rectal cancers can be palliated by fulguration (electrocoagulation) or laser photocoagulation. Chemoradiation: Chemoradiation can be given as adjuvant or neoadjuvant therapy. "In this patient the tumor lies 3.5 cms above the anal verge (the lower limit is taken into consideration). Dentate line is just 2 cms from the anl verge so the tumor is just 1.5 cm from the dentate line. A minimum margin of 2 cm is required below the tumor for sphincter saving LAR, so the patient will have to go an APR procedure to remove the tumor". Ref: Sabiston 18/e, Page 1413; Schwaz 9/e, Page 1028; CSDT 13/e, Page 664; Devita's Oncology 8/e, Page Chapter 3, Section 13.
Colostomy
Anterior resection
Abdominoperineal resection
Dysfunctional anastomosis