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Rectal Cancer

 

Carcinoma of the rectum

 

Where is the rectum located?

The rectum is defined as the last 16 cm of the large Intestine, starting from the anus (Fig. 1) It lies completely in a small pelvic and connects to the S-shaped intestine (Sigma) (Fig. 2). It follows the curvature of the lower spine and runs partially into the abdominal cavity and partially into the retro peritoneum, which is located behind the abdominal cavity. In men there is a close relationship between the rectum and the Prostate and in addition to the seminal vesicles. In women, the rectum is located behind the vagina and the uterus. The anatomical location of the rectum influences the process of a possible tumour and it is of great importance for the diversity therapeutic strategies.

enddarm organe

Functions of the rectum

The rectum, defined as the last section of the colon, occupies an exceptional position. It differentiates by its unique location as well its duty from the other parts of the colon. While other parts of the colon concentrate on the reclaiming of fluids from faeces into the organism, the rectum will perform as basin, in which the faeces is gathered and later on expelled. This Process is most crucial to our daily lives.

Additionally the rectum plays an important role in the mechanism of defecation. The defecation is a very complex procedure and depends on numerous factors. Such as the anatomical circumstances of the pelvic floor muscles, the sphincter but as well the healthiness of the rectum. If one of them is disturbed it will influence the defecation negatively.

Malignant rectal cancer

In medicine we can generally distinguish between primary and secondary Tumours.
A primary malignant rectal cancer is a Tumour which grows in the rectum and contains the characteristics to infiltrate itself into the intestinal wall and to form metastasis. The metastasis of the tumours can be swept into the lymphatic system or via the bloodstream into the liver and subsequently swept into the lungs, in which it will develop itself.

Likewise in other parts of the large intestine, the adenocarcinoid is the most common malignant rectal cancer. However the shape of the tumour can vary within the intestine. It can grow petiolate, crater-shaped, diffuse or even ring-like which will then narrow down the intestinal lumen.
The early symptoms may vary, depending on the manifestation which may be associated with the tumour.

The cause of the origin of this malignant rectal cancer is not known yet.
There is a discussion whether Genetic or nutritional factors such as a high fat content could be the cause. However there are some other risk factors which certainly contribute to rectal cancer.
This can include specific pre-diseases of the intestine such as colitis ulcerosa, crohns’ disease and the polyposis coli.

The latter is considered to be precancerous (pre-cancer) because of the many outgrowths of the intestinal mucosa (polyps) which after a certain time become malignant. Also a known family history of malignant intestinal tumors in the same family can increase the possibility of developing such a tumor.

How do I recognize a carcinoma of the rectum?

Unfortunately the first symptoms of this tumour in a patient are heterogeneous. If the intestinal lumen is transferred by the tumour, it may come to stool irregularities (such as diarrhoea alternating with blockage) or to colicky pain and flatulence. Some tumours may bleed frequently which will lead to blood shortage (anaemia). If a discharge of blood is found through the anus, or if the patient detects any blood in his stool, one should immediately consult a doctor for clarification. The doctor will then clarify whether the discharge of blood relates to haemorrhoids or has others serious causes. This type of Tumour may lead to weight loss and confinement of physical health. In some cases it may come to an intestinal obstruction (Ileus). This is mostly distinguished by lack of wind-and stool dejection for days as well an increase of colicky pain.

Necessary clarifications and diagnostic possibilities

Various Gastro-Intestinal-diseases may cause the above mentioned complaints. Therefore the physician needs to know the exact expiration of one’s medical history. Questions such as “Since when have you felt any pain in your stomach and endured stool irregularities? Is there any relation between the complaints and your ingestions of nutrition?
Do you experience weight loss or a reduced performance in your physical health?”  will be part of the  conversation with the physician. Other questions concerning blood deposits on ones’ stool will also be part of the Questioning.  For instance “Did anybody in your family history endure specific intestinal diseases or a colon carcinoma?”

After the clarification, the physician will examine your stomach and feels if there is a large amount of flatulence, a tumour or even other diseases such as hernias of the abdominal wall.
Since the majority of malignant abdominal tumours are found in the rectum, a digital examination of the patient is an important part of the diagnosis. The physician will feel with his fingers through one’s anus its rectum, sphincter function and especially if there are any irregularities in the prostate in men. Afterwards the patient will go through a laboratory investigation to exclude if there is a shortage of blood or if other organ functions containing typical tumour markers.

If the suspicion of Cancer has been confirmed, the patient has to undergo a colonoscopy (Fig. 3) so that the physician can take tissue samples from suspicious parts of the mucous membrane.

 


Furthermore the patient will undergo an ultrasound scan of the patients’ stomach, so that the physician can evaluate the liver, gall bladder, bile trails, pancreas and kidneys. Depending on the size of the tumour as well as other comorbidities the patient will undergo numerous examination procedures.
Such as CT-examination, MRI (fig. 4), endosonography of the rectum (the exact location of the tumour is of great importance for the operation planning), cardiac sound or even pulmonary function test.

How is a rectum carcinoma treated?

If the diagnosis of a rectal cancer has been confirmed, the only option would be a surgical intervention. However, as already mentioned, the process of this operation differentiates from other cases of a colon tumour. Depended on the size of the tumours – The rectum is divided in three segments – a radio treatment before the operation would be useful in addition to chemotherapy. It is known that with help of those therapies the size of the tumours will be reduced; furthermore potential tumour cells can be treated in lymph nodes. After finishing this combined radio/chemotherapy the operation will begin.

Before the operation an intestinal cleansing is carried out, so that there will be no infections through germs by the removal and joining together of the intestinal sections. For this reason each patient receives antibiotics before and after the operation. The aim of the operation is to remove the tumour and the corresponding lymph nodes and the reintegration of the intestinal sections. The curative therapy of a rectum carcinoma will be achieved by an anterior (front) rectum resection. The access to the abdominal cavity will be accomplished by a middle abdominal incision (Fig. 5) or laparoscopy.

The surgeon will then focus on the lower belly and searches for the tumour supporting section of the intestine. According to the preliminary investigation, the surgeon knows exactly in which section the tumour is located. This knowledge is of great importance for the planning of such an operation. Especially the interval between tumour and anus should be taken in consideration since at some point a reunification of the intestinal parts will happen. To remove an intestinal section in the rectum, the previous section has to be loosened up from the underground and additionally mobilized. By malignant tumours the belonging lymph nodes are being located and removed from the large vessels. The vessels which start from the middle of the stomach to the mesenteries are being set centrally (Fig. 6). Thereby the whole drainage area of the lymph with the lymphatic and the lymph nodes are being removed. This step is very important. A chemotherapy after the operation is fatal when the lymph nodes are affected by a tumour. Subsequently the rectum is being mobilized in which the surgeon should pay attention not to harm both ureters.

The rectum is located in a mantle of adipose tissue ( mesoctum) in which the vessels and lymphatics run through.To treat existing metastasis, the mesorectum is being removed. This modern surgical method (TME- total mesorectal excision) is introduced in 1985 from professor Bill Heald. In gratitude to this technique, the nerves which are very important for male potency and are close to the part where the rectum is removed ,can be therefore retained.

In the next step, the continuity of the intestine is being re-established. This requires stapling devices. They enable the surgeon an anastomosis (reunification) of the intestine, even though it’s few centimetres away from the anus. (Fig. 7)

A Method, which unfortunately can’t be avoided and may release psychological distress in a patient, is the installation of a synthetic anus (Anus Praeter). Its’ function as drainage of stool and gas from a section of the intestine via abdominal wall outwards into a sachet. Depending on which intestine (small or large) is being drained from, we speak of an Ileostomy or colostomy. A stoma is a short- term method with the aim to establish the intestinal continuity by a shift back.

Reasons for a stoma can vary:

1. Threatening intestinal obstruction by an unresectable tumour.

2. Very deep, near to the sphincter located tumours. Therefore the sphincter has to be removed as well…

3. ..to protect an anastomosis, until it is healed.

To position a stoma, the surgeon has to prepare a sufficient incision in the abdominal wall. Through this opening the intestine is pulled outwards and carefully sewed to the abdominal wall. The new intestinal opening will then be supported by a special sachet. Many patients feel discomforted, embarrassed and no longer socially acceptable because of the stoma device even though the materials which were used are excellent in quality A solution to overcome this psychological burden would present a self-help group (ILCO), which will support the affected patients. In addition there are as well special care professionals, the so called Stoma therapist which will help them through the patients’ everyday life. A special case would be if small narrow tumours would display on the rectum. These tumours can be removed via trans- anal endoscopic microsurgery (Fig. 3). Therefore a special recto scope (metal tube with lens system) is needed which will cut out the carcinoma via the anus. This way the patients doesn’t have to endure an operation which would involve abdominal incision. In general a treatment strategy can only be planned if the evaluations of diagnostic findings have been carried out carefully. The treatment will then be customized for each patient individually to achieve greater security.

What happens after the operation?

In general the patient will be supervised one to two days after the operation. The laboratory values are being checked, pain- and infusion therapies are given to the patient and the intake of antibiotics will be continued. Due to the intestinal anastomosis, the patient shouldn’t drink nor eat for some days. This should prevent the leakage of the sewage in the intestine. Over time the patient may begin to drink. This may be a painful experience since the intestine is partially overinflated and the laxation is still slow. Over time more and more nutrition can be added to the patients’ diet through soup or vegetable purées.
 
Physiotherapists will additionally take care of the patients because of their limited mobility. If there were any drainage involved in the operation, they will be removed over time.

All tissue removed during the operation will be sent to a pathologist for histological examination.
He will then evaluate the tumour, the surgical margins and lymph nodes which will help to determine at which Tumour stage it was. Once we got the final result of the pathologist, we will discuss with the patient and his family members, if desired, the findings and possible consequences. After major abdominal surgery, the body needs time to convalescents. Therefore most of the patients take the possibility for rehabilitation directly after their stay at the hospital. The arrangements are planned during the hospital stay. The individual follow-up of each patient is prepared according to the tumour stage. At certain intervals tumour-markers are being checked. In addition, ultrasound or CT scan are taken from the abdomen and a colonoscopy to make sure that no metastases have occurred or that no new tumour has developed.

History

Only 150 years ago two thirds of the patients died because of internal organ surgery. Reasons for such a high rate of mortality were the lack of anesthesia, antisepsis and one specific reason, the “Shock”. This phenomenon is caused by a high blood loss or even submerged bacteria which can end deadly.

However over time groundbreaking discoveries were made which still form the foundation of our surgery nowadays.
In 1844, the first anesthesia with nitrous oxide was invented by Horace wells. 1901 Karl Landsteiner discovered the blood groups of humans. This opened the possibility of blood transfusions during a major surgical operation which will successfully confront the hemorrhagic shock.

Yet the greatest achievement was held by Ignaz Philipp Semmelweis. In his time wound infections, particularly puerperal fever, caused by the lack of hygiene of hands and instruments were common. Thorough hand hygiene in hospitals was completely unknown. Bacteria were carried, without knowing it, from one patient to the other. Unfortunately, Semmelweis was too far ahead of his time. To disinfect ones hand with carbolic acid seemed to be joke, although Luis Pasteur the famous discoverer of bacteria demonstrated the effectiveness of Semmelweiss discovery. The surgeon Joseph Lister in Glasgow was the first one who had heard the ideas of Semmelweis and 1869 and established the use of disinfectant in his clinic. With success.

Before surgery, the surgeons’ hands were washed with soap containing carbolic. In addition a solution containing carbolic was sprayed on to the area of operations. Owing to the carbolic solution and pre-hand wash the number of complications decreased significantly .With this awareness, operating rooms were only allowed to enter with a hood and mask. Over time more and more major abdominal surgeries performed aseptically and therefore became more successful. In respond to this successful discovery Professor and surgeon Ulrich Kroenlein who worked since 1881 at the University Hospital in Zürich acted very quickly. The idea of an antiseptic environment in a hospital went from exceptional to standard in hospitals.
He simply removed the wooden beds and built a new operation theater in form of the roman Amphitheatre (for class).
Kroenlein was the first surgeon who operated acute gastroenteritis and studied the treatment for purulent peritonitis which occurred after intestinal injury.

Peritonitis I caused by poor gut sutures (anastomosis). Therefore two famous surgeon at that time, Vinzenz Czerny and Theodor Kocher, are searching for a new sutures technique in intestinal surgery.
“The intestinal resection has become an extremely important and relatively frequent surgical intervention. If correctly performed, a surgeon can save lives which normally would be hopeless.”
This sentence was written by the Swiss surgeon and first Nobel prize winner for medicine (1909); Theodor Kocher , which introduced his intestine sutures (Boschung U.: Milestones in the history of intestinal anastomosis, Swiss Surg 2003: 9: 99-104). Sir Ernest Miles performed in 1907 the first radical abdomino-perineal resection in rectal cancer. He removed parts of the large intestine and the entire rectum.

The development of diagnostic possibilities, modern intensive care such as oncology (the study of tumor) and even technical development opens us a wide range of individual therapy concepts which can be used to treat colon cancer.

 

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