<prompt> A 65yr old male patient presents with history of early morning bloody diarrhoea, Change in bowel habits, Intermittent Obstruction.Sometimes he had a feeling of incomplete evacuation and Tenesmus. There is no positive family history for any carcinoma.What will be the treatment of choice in this case:Total mesorectal excisionHamanns procedureAnterior resectionAbdominoperineal resection  <response>: CA rectum- MC site of large bowel malignancy- Usually seen in 5th - 6 decade- MC site of metastasis - Liver lungs - Chemotherapy regimen- FOL FOX-IV FOL - Folinic acid leucovorin F- 5-FV 5-Flurouracil Ox- Oxaliplatin Clinical features- MC symptom - Bleeding PR- Early morning bloody diarrhea- Passage of bloody slime no fecal matter - Spurious diarrhea every 2 to 3 hours, rectum is full with discharge from tumor, so patient passes like stool every 3 hours- Tenesmus - Painful defecation with sensation of incomplete evacuation seen in lower pa of CA rectum- Back ache sciatica sacral plexus involvement posteriorly- Weight loss liver metastasis Investigations- Length of anal canal - 3cm- length of rectum - 14cm- For complete evaluation, the length of the instrument should be at least 17 cm Investigations Options available- PROCTOSCOPY- Sigmoidoscopy- Colonoscopy Length of proctoscope - 10 cm Rigid sigmoidoscope -25 cm Flexible sigmoidoscope- 60cm Colonoscope - 160 cm- Investigation of choice - Rigid sigmoidoscopy biopsy- Colonoscopy is mandatory for adequate evaluation of whole colon and to rule out any synchronous polyp or synchronous malignancy Synchronous- simultaneously Metachronous- later after surgery- Viual colonoscopy 3D reconstruction colonoscopy using CT Advantage - can visualize outside of lumen also Disadvantage - Biopsy of colon cannot be done- In head neck malignancies pelvic malignancies, overcrowding of nerves, blood vessels soft tissues. So, IOC for staging of most of head and neck malignancy- MRI- For T- staging, investigation of choice- TRUS Transrectal ultrasound- Distantly lying nerve, lymph node, vessel cannot be differentiated as Sensitivity of ultrasound decrease if distance between probe organ increase. - For lymph node staging, investigation of choice is - Endorectal MRI- Overall Best investigation for staging- MRI Treatment- Principle of treatment in CA Rectum Stage I - Surgical resection State II III - Neoadjuvant chemoradiation followed by surgical resection down stage the tumor then surgery Stage IV - Neoadjuvant chemoradiation followed by palliation - surgical excision - TOC- TOTAL MESORECTAL EXCISION Given by Bill Heald Significant length of bowel removal around the tumor Removal of Surrounding tissues up to the plane between Mesorectum Presacral Fascia known as HEALDS HOLYPLANE - If CA rectum is located 5 cm above Anal verge - Low Anterior Resection LAR- If CA rectum is located at or below 5 cm from anal verge - APR Adomino Perineal resection aka Miles Procedure - In elderly patient 60 years with malignancy in sigmoid or proximal pa of rectum which is intraperitoneal - Hamans procedureHamans procedure Sigmoidectomy Descending colostomy Closure of rectal stump 