Rectal cancer is the cancer that begins in the rectum that occurs when cells in the rectum mutate and grow in an uncontrolled manner. Rectal cancer is grouped together with colon cancer as both share many similar features. There are several causes and risk factors for rectal cancer which include age, diet, obesity, uncontrolled diabetes, sedentary lifestyle, and alcohol use. In the past, rectal cancer treatment was quite difficult, however due to the treatment advances rectal cancer survival rates has extensively improved.
Two patients previously diagnosed with locally advanced rectal cancer have undergone ultralow anterior resection, 3-4 cm from the anal verge. As a multidisciplinary team, the patients received neoadjuvant chemo radiation, we advised them both to do abdominoperineal resection (APR), because it was hard to preserve the anal sphincter in an alternative way. However, these patients refused and did Colo-anal anastomosis in different institutions under their own responsibility, this resulted in several complications as previously expected pre-operatively, and these complications included soiling, incontinence, and stenosis due to the radiotherapy effects preoperatively. As a result of these complications, we are planning to either divert them or to disseminate the anastomosis .Below are figures demonstrating pelvic MRI, showing rectal mass 3-4cm from the anal verge (Figure 1).
Rectal cancer screening typically starts at the age of 45 years, sometimes at younger ages in those who are more susceptible. In early stages of rectal cancer, it asymptomatic and usually detected during routine screening examinations. Most common symptom is change in the bowel habits that may include constipation or diarrhea , blood in the stool, or narrow shaped stool. Rectal cancer staging is divided into local and distant staging, local staging is done via MRI or endoscopic ultrasound, distant staging is achieved via CT scan, or PET scan. Staging at the time of the diagnosis is considered to greatly influence the prognosis, cancers that are confined to the lining of the colon have better outcome. Surgery is considered the gold standard treatment in rectal adenocarcinoma, excision could either be local or radical and this is dependent on the tumors clinical stage, size, as well as the location of the primary tumor . There are several surgical methods done in the management of rectal cancer dependent on the stage , for patients with invasive rectal cancer , local excision is not possible therefore radical transabdominal resection is needed, in such cases if a negative distal margin can be achieved low anterior resection is performed (LAR). However, if adequate distal margin is not present or if there is poor presurgical anorectal function then Abdominoperineal Resection (APR) is required . Abdominoperineal Resection (APR) is corner stone for treating low-lying rectal cancer, it’s a surgical procedure which involves the removal of both the rectum and anus, which completely removes the distal colon, rectum, and anal sphincter, resulting in a permanent colostomy. APR outcomes are associated with decline in the sphincter function, so the patient will experience increased stool frequency, incontinence, decreased rectal compliance and incomplete evacuations. As a result of these outcomes the patient will suffer from low quality of life. In a previously prospective study conducted, results concluded that patients who had anastomosis 5cm of the anal verge had significantly the worse quality of life compared to those who underwent APR, and this supports our two cases in this case report .
APR is a morbid and radical procedure, but due to the great medical advances as neoadjuvant therapy, this tended to eliminate a great number of patients from this procedure. Neoadjuvant therapy tends to downstage rectal tumors as a result patients will undergo sphincter sparing surgeries. In conclusion, the earlier the diagnosis the better the prognosis under the management of a multimodal approach by achieving a good oncologic outcome together with maintaining a desirable quality of life.
Figure 1: Demonstrating pelvic MRI, showing rectal mass 3-4cm from the anal verge.
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