Special Considerations

There are special considerations that require modification in evaluation and/or operative approach to rectal cancer.

Colonic J-Pouch

An ultralow anastomosis to the distal anal canal often results in urgency, frequency, partial incontinence, and clustering of bowel movements. To improve function, we often create a 5-cm colonic "J "pouch using descending colon and anastomose the apex of the "J " to the rectal or anal remnant. Forming such a reservoir has been demonstrated to improve function especially in the first year post operation but has the potential disadvantage of interfering with complete evacuation of the rectum.

Laparoscopic Resection

Although laparoscopic resection for colon cancer is gaining acceptance, laparoscopic resection of rectal cancer is in its infancy. The high level of difficulty of the procedure and the need for meticulous mesorectal excision may limit this approach to all but a few expert centers.

En Bloc Resection

Because the pelvis is a fixed and relatively narrow space, rectal cancers may involve contiguous structures. Such T4 tumors may still be cured with surgery and adjuvant therapy, however it is essential that involved organs (or portion thereof) are resected with the rectum in an en bloc fashion. Peeling tumor off adjacent organs will almost certainly leave disease behind and predispose to local recurrence. Anterior tumors in women may necessitate a hysterectomy or a posterior vaginectomy. similarly such tumors may require bladder resection and urinary diversion. With posterior tumors, en bloc sacrectomy may occasionally be necessary. Even when such a radical approach is required, if an R0 resection (complete resection, no residual disease) can be performed, a significant number of patients will be long term survivors.

Emergent Cases

Approximately 10% of patients with rectal cancer will present emergently, most commonly with increasingly symptomatic obstruction. Rarely, this progresses to a complete large bowel obstruction with a risk of intestinal perforation. Large volume lower gastrointestinal bleeding is far less common but can occur. Workup and treatment paradigms must be adjusted in the face of emergency presentation. The first priority must be prevention or treatment of life threatening complications. For patients who present with impending obstruction, an endoscopically or fluoroscop-ically placed colonic stent may temporally relieve the obstruction, allowing the patient to be treated in a more standard elective fashion. There are two chapters on rectal stenting (see Chapter 86, "Acute Colonic PseudoObstruction" and Chapter 99, "Palliative Therapy for Rectal Cancer"). Though useful in rectosigmoid and proximal rectal obstructing cancers, stenting is not possible in low-lying rectal lesions. If complete obstruction or perforation has occurred, emergent operative management is almost always necessary to relieve the obstruction and control the peritoneal contamination. If technically safe, the rectal cancer should be resected at the initial operation. However, if the disease is advanced, if adequate treatment would require an APR, or if the patient is unstable, enteric diversion by formation of an ileostomy or colostomy followed by complete postoperative evaluation, consideration of neoadju-vant therapy and subsequent definitive treatment may be the most prudent course.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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