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Tumori benigne de rect si

prolapsul anorectal
Pot lua nastere din fiecare componenta
structurala a rectului. Cele mai
frecvente tumori benigne ale rectului sunt
reprezentate de adenoame, care nu numai ca
nu sunt rare dar se pot si asocia cu cancer
rectal sau pot evolua spre transformare
neoplazica.
1. Adenoamele rectale

Adenoamele sunt de obicei polipoide si variaza considerabil in


dimensiuni, forma si grad de diferentiere histologica.
Toate adenoamele au punctul de plecare la nivelul unei singure
cripte (microadenoame), crescand gradat in dimensiuni.
Adenoamele tubulare, bine diferentiate, sunt cele mai frecvente si
sunt mai ales pediculate, mai ales cand sunt mari.
Prin contrast, adenoamele viloase, mai putin diferentiate, sunt mai
putin frecvente si invariabil sesile, intinzandu-se frecvent pe mai
multicentimetri. intre cele 2 forme descrise se situeaza adenoamele
tubuloloase.
Adenoamele viloase
mai ales pot produce simptome dramatice datorita depletiei
electrolitice; simptomele sunt datorate predominant productiei de
mucus, care se manifesta ca o descarcare rectala, uneori colorata cu
sange, sau ca diaree mucoasa.
Leziunile din jumatatea joasa a rectului sunt palpabile;
tipic un adenom vilos se simte moale si catifelat; induratia unei
parti a leziunii sugereaza modificare maligna, un eveniment relativ
comun in leziunile mai mari de 2-3 centimetri in diametru.
Vazuta printr-un sigmoidoscop, aceasta leziune are o culoare mai
intunecata decat mucoasa normala si poate fi recunoscuta
suprafata loasa.
Principalele tehnici pentru detectia bolii adenomatoase sunt
endoscopia si clisma baritata cu dublu contur.
Tratamentul
pentru adenoamele foarte mici este cauterizarea-biopsie.
Polipii mai mari sunt excizati endoscopic, iar cei peste 5 cm
sunt scosi bucata cu bucata utilizand electrocauterul pentru
a coagula si distruge baza de implantare.
Complicatiile polipectomiei endoscopice sunt rare cand se
realizeaza cu multa atentie, dar cele mai serioase dintre
acestea sunt perforatia si hemoragia.
Adenoamele viloase rectale sesile mari nu sunt potrivite
pentru inlaturarea prin endoscopie si uneori reprezinta
subiecte pentru chirurg.
Lipom rectal
Schwanom retal
RMN
TRATAMENT ENDOSCOPIC (TEM)
EX HISTOPATOOGIC
Calcifying fibrous tumor presenting
as rectal submucosal tumor
A case of primary rectal angioleiomyoma: review of
radiologic finding with histopathologic correlation
Transanal minimally invasive surgery for rectal tumors

(a) Endoscopic view of a tumor before excision, pre-operative biopsy revealed an intramucosal carcinoma pTis-cN0.
(b) Endoscopic view of the full thickness excision area, perirectal fat is exposed. (c) Endoscopic view of the closed
surgical defect with running sutures with regular straight laparoscopic needle holder. (d) Excised tumor: Margins are
circumferentially tumor free, final histology showed a T1 adenocarcinoma
Transanal endoscopic microsurgery (TEM)--alternative or a method
of choice in treating tumors of the rectum with appropriately
selected patients?

TEM is an endoscopic method of


operating tumors up to 18 cm of the anal verge.
It enables procedures from a simple
mucosectomy to en-block excisions of the whole
thickness of the rectal wall.
TEM is a safe and appropriate surgical treatment
option for benign rectal tumors and for early-
stage rectal carcinomas.
TEM is also good as a palliative method, and it's
useful for elderly and unfit patients.
Transanal endoscopic microsurgery (TEM)

is a minimally invasive technique for the removal of large polyps localized in the
rectum and not amenable to endoscopic resection .
While transanal local excision with retractors is associated with a significant
incidence of local recurrencein particular for tumors located in the proximal
rectum.
TEM provides a transanal approach with low recurrence rates, thanks to an
extremely precise dissection due to enhanced and stable visualization of the
surgical field.
In addition, the full-thickness en bloc excision allows accurate pathological
evaluation of the specimen with precise staging of the disease.
Compared with abdominal surgery, TEM offers the advantage of combining a
minimally invasive approach with evident benefits in terms of postoperative
morbidity and recovery and long-term functional outcomes and quality of life .
While TEM has revolutionised technique and outcome of transanal surgery,
becoming the gold standard for the treatment of large rectal adenomas ,
concerns remain about its role in the treatment of rectal cancer, mainly due to the
lack of adequate lymphadenectomy.
SURGICAL TECHNIQUE
In many centers, a TEM procedure is now performed with TEO
(transanal endoscopic operation) instrumentation by Karl Storz
GmbH (Tuttlingen, Germany).
The equipment includes a 7 or 15 cm rectal tube which has a 4 cm
diameter and three working channels (12, 5 and 5 mm) for
dedicated or conventional laparoscopic instruments and a 5 mm
channel for a 30 2D scope.
The proctoscope is connected to the operating table via a holding
arm consisting of three joints and a single screw. The system is used
in combination with standard laparoscopic units.
Camera imaging is projected on screen and insufflation is obtained
by a conventional CO2 thermo-insufflator. The shape of the tip of
the proctoscope allows manipulation and suturing of the rectal wall
on a 360 surface.
Recently, transanal minimally invasive surgery (TAMIS), using
equipment for single-incision laparoscopic surgery (SILS), has been
proposed as an alternative to TEM.
Indications and surgical technique are the same as for TEM.
The TEM procedure is usually performed under general anesthesia.
The patient is placed either prone or supine in order to keep the lesion
as close to the 6 oclock position as possible.
Patients with lateral lesions are usually placed in the supine position
unless the lesion is predominantly located in the right or left upper
quadrant (i.e. 12 to 3-, or 9 to 12 oclock position). With circumferential
lesions, the patient is always positioned prone due to the higher risk of
entering the peritoneal cavity and the consequent need to reduce the
descent of small bowel loops into the surgical field while repairing the
opening itself.
After insertion of the proctoscope, the lesion is identified and the
proctoscope is fixed. Its position is adjusted throughout the procedure
in order to ensure optimal visualization and access to the margins of
the lesion. High-flow CO2 insufflation is required and endoluminal
pressure is generally maintained at 8 mmHg, although it might need to
be increased to 16 mmHg.
Dissection usually begins at the right lower border of the tumor. A
macroscopic margin of at least 5 mm from the neoplasm needs to
be obtained with both benign and malignant lesions. Tumor
excision is performed by monopolar hook cautery. In difficult cases,
ultrasonic shears or an electrothermal bipolar vessel sealing system
may be helpful. Dissection is continued circumferentially around the
lesion to the perirectal fat.
Due to the uncertainty of the pre-operative diagnosis and staging,
full-thickness resection with adequate margins of clearance should
be performed.
The specimen is retrieved transanally and is pinned on a corkboard
before fixation in 10% buffered formalin, in order to preserve the
margins of normal mucosa surrounding the tumor. The specimen is
analysed by permanent section.
Transanal minimally invasive surgery (TAMIS): new treatment
for early rectal cancer and large rectal polyps

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for


excision of rectal tumors that avoids conventional pelvic resectional surgery .
Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to
TEM.
This platform uses ordinary laparoscopic instruments to achieve high-quality
local excision.
After a single-incision laparoscopic surgery port was introduced into the anal
canal, a pneumorectum was established with a laparoscopic device followed
by transanal excision with conventional laparoscopic instruments, including
graspers, electrocautery, and needle drivers.
The median length of the lesions from the anal verge was 7 cm (range, 4 to 20
cm).
The median operating time was 86 minutes (range, 33 to 160 minutes).
The median postoperative hospital stay was two days (range, 1 to 4 days).
TAMIS seems to be a feasible and safe treatment option for early rectal cancer.
We believe that this new technique is easy to perform, cost-effective, and less
traumatic to the anal sphincter compared with traditional TEM.
Prolapsul rectal
reprezinta protruzia (iesirea) rectului si ocazional
a sigmoidului prin anus, acestea fiind vizibile in
afara corpului.
Exista doua tipuri de prolaps rectal: partial si
total.
Prolapsul partial apare atunci cand prolabeaza
doar mucoasa rectului si prolapsul
total sau procidenta rectala -cand sunt
exteriorizate prinorificiul anal toate tunicile
rectului.
Cauzele prolapsului rectal
In mod normal rectul este sustinut in pozitia fiziologica de o serie de
ligamente si muschi. Slabirea mijloacelor de sustinere a rectului determina
alunecarea acestuia prin orificul anal catre exterior.

Cele mai comune cauze care favorizeaza aparitia prolapsului rectal includ:
inaintarea in varsta si cele mai frecvent afectate sunt femeile;
utilizarea pe termen lung a medicamentelor care au efect constipant;
histerectomia (indepartarea prin interventie chirurgicala a uterului);
traumatismele scad tonusul musculaturii;
tumori rectale;
cresterea persistenta a presiunii intra-abdominale (tuse, constipatie).
Tusea persistenta este determinata de boli cronice pulmonare (fibroza
chistica, BPOC);
leziuni ale coloanei vertebrale.

Prolapsul rectal poate sa apara la copii pana la varsta de 3 ani, cauza fiind
necunoscuta
Semnele si simptomele prolapsului
rectal
Protruzia rectului prin canalul anal este retractila in primele stadii sau poate
fi redusa manual.
Ulterior, in formele mai avansate, cand rectul nu mai poate fi introdus manual
prin canalul anal, se constata prezenta unei mase voluminoase protruzionata
prin orificiul anal.

Semnele si simptomele prolapsului rectal includ:


durere in zona anala;
exteriorizarea unei mase prin orificiul anal, la inceput in timpul defecatiei,
apoi la eforturi minime;
sangerari anale;
mancarimi in zona anala;
stare de nervoziate;
senzatie de discomfort determinata de masa protruzionata prin orificiul
anal;
incontinenta fecala (eliminare involuntara a materiilor fecale) progresiva;
materiile fecale contin o cantitate crescuta de mucus.
Diagnosticul de prolaps rectal
Incontinenta fecala, durerea, sangerarile anale, discomfortul simtit la
alunecarea prin anus a rectului sunt simptome care obliga persoana in
cauza sa mearga la medic.

Pentru stabilirea diagnosticului de prolaps rectal sunt necesare o serie


de examene paraclinice si examene de laborator :
examen local al zonei pentru confirmarea diagnosticului precum si
pentru infirmarea altor afectiuni (hemoroizi , tumori)
colonoscopia sau clisma baritata pentru evaluarea completa a
colonului si excluderea altor afectiuni care ar putea sa favorizeze
prolapsul rectal;
analize de sange sunt obligatorii pentru evaluarea pacientului;
manometria anala utila pentru evaluarea stadiului prolapsului anal;
electromiografia anala este folositoare la persoanele cu prolaps
rectal in scopul alegerii procedeului de reconstructie cel mai eficient.
Tratamentul prolapsului rectal
Prolapsul rectal este o problema majora de sanatate intrucat creeaza, pe
langa discomfort, si numeroase alte prejudicii (incontinenta anala, durere)
asa incat tratamentul trebuie instituit urgent.
Tratamentul chirurgical vizeaza fixarea rectului prin diverse mijloace in
functie de gravitatea prolapsului rectal si de cauza care a determinat
aparitia acestei afectiuni.
La persoanele cu prolaps rectal complet la care functia sfincterului anal
este complet pastrata, interventia chirurgicala implica rezectia anterioara
joasa cu fixarea ligamentelor rectale laterale.
Pacientii cu procidenta rectala si incontinenta anala beneficiaza
de interventie chirurgicala reparatorie prin fixarea retro-rectala sacrala
folosind o "esarfa" sintetica .
Prolapsul rectal asociat cu un risc operator crescut sau la persoanele in
varsta beneficiaza de tratament chirurgical prin procedeul de incercuire
a sfincterului anal.
Prolapsul rectal la copii beneficiaza de tratament conservator (defecatie
in pozitie culcata, pomezi si tratamentul constipatiei) si tratament
chirurgical (cerclaj anal).