Surgical Pathology of the Colon and Rectum PDF

Surgical pathology of the colon and rectum Prof. Dr. Dorel Firescu Elements of colon anatomy ♦ The colon is the second last segment of the digestive tract; ♦ extends from the ileocecal valve to the junction with the rectum (S3 vertebra); ♦ the length is 1.5m; ♦ the 8 cm diameter at the...

Surgical pathology of the colon and rectum Prof. Dr. Dorel Firescu Elements of colon anatomy ♦ The colon is the second last segment of the digestive tract; ♦ extends from the ileocecal valve to the junction with the rectum (S3 vertebra); ♦ the length is 1.5m; ♦ the 8 cm diameter at the cecum tapers towards the recto-sigmoid junction (4- 5cm); ♦ has the following portions: ▪ check; ▪ ascending colon; ▪ transverse colon; ▪ descending colon; ▪ sigmoid; Colon division - can be done from several points of view: Embryologic The colon can be divided into 2 segments: right colon represented by: ▪ check with vermiform appendix; ▪ ascending colon; ▪ right half of the transverse one; left colon ▪ between the splenic angle to the pelvic diaphragm; Anatomotopographically - the colon can be divided into the following segments: ▪ ascending colon; ▪ right colic flexure; ▪ transverse colon; ▪ left colic flexure; ▪ descending colon; ▪ iliac colon; ▪ pelvic colon; Physiologic and radiologic - the existence of Cannon's sphincter, which divides the colon into: ▪ right colon - for digestion and absorption; ▪ left colon - passage; ▪ pelvic - stasis colon;  Depending on its fixity or immobility, the colic frame is divided into: ▪ Mobile segment: ▫ Transverse colon; ▫ sigmoid colon; ▪segmente fixe: ▫ ascending colon; ▫ descend; ▫ liver flexure (right colic); ▫ splenic flexure (left colic); Check ♦ is the first portion of the colon; ♦ lies in the right iliac fossa; ♦ between 6 and 7 cm in both directions; ♦ describe the check: ▫ Bauhin's or ileocecal valve: - makes the boundary between ileum and cecum; - allows intestinal contents to pass in one direction, from the ileum to the cecum; - consists of two labia and two commissures; ▫ vermiform appendix - vestigial organ - will be presented in appendiceal pathology; ♦ the check can be : ▫ high or low; ▫ can be mobile or fixed; ♦ according to some authors the check is a separate entity, beyond it the colon; Ascending colon ♦ is the first portion of the colon; ♦ is about 12-15 cm long; ♦ extends from the junction with the cecum  right colonic = hepatic flexure; ♦ is crisscrossed by three taeniae = condensed longitudinal muscle fibers; ♦ shows some trensverse grooves between which the so-called haustrals of the colon are delimited; ♦ occupies the entire right flank from the right iliac fossa to the right hypochondrium; ♦ between it and the abdominal wall is a space called the right parieto-colic space (groove); ♦ Between the base of the mesentery and the ascending colon, the right mesentericocolic trench is formed;  Transverse colon ♦ about 45-50 cm long; ♦ is diposed between the two flexures, right or hepatic colic and left or splenic colic; ♦ has an oblique direction from right to left and from bottom to top; ♦ is an intraperitoneal organ; ♦ is connected to the posterior wall of the abdominal cavity by the transverse mesocolon, which follows the course of the colon; ♦ in its path through its root, crosses: ▫ duodenum; ▫ cephalopancreas; ▫ reaching the left kidney and spleen; ♦ the three tapeworms continue into the transverse colon; ♦ the anterior free tenia representing the insertion site of the greater omentum; ♦ from the surface of the transverse colon, thick extensions start = called epiploic appendages; Descending colon ♦ is about 25 cm long; ♦ extends from the splenic flexure to the left iliac fossa; ♦ continues with the sigmoid colon; ♦ it is a retroperitoneal organ, so fixed organ; ♦ occupies the left flank; Sigmoid colon ♦ continues the descending colon for about 40 cm; ♦ from the upper pelvic inlet to the rectum; ♦ corresponds to the third sacral vertebra (S3); ♦ is intraperitoneal organ; ♦ is connected to the posterior wall by the mesosigmoid; ♦ this gives it great mobility, ♦ the three tenii here condense into two: ▫ previous; ▫ posterior; ♦ The haustrils are much more obliterated than the rest of the colon;  COLON PHYSIOLOGY Digestive function ♦ is performed on unabsorbed products in the small intestine; ♦ the function is provided by bacterial flora, rich at this level; ♦ colonic and differentiated digestion: in the right colon for: - carbohydrate; - glyceride; - cellulose; - the reabsorption of water and electrolytes continues;  in the left colon for: - proteins from which by puterfact: ▫ indol; ▫ box; ▫ ammonia(NH );3 Colic motility: ♦ ensure progression of feces to the sigmoid; ♦ daily fecal volume of 100-150 ml; Colon movements Segmental contracts segmental contractions + extrinsic changes in tone  mix intestinal contents; ▫ are regular; ▫ at small intervals (2-3/minute);  Peristaltic waves propels fecal matter accumulated in the colon to the rectum; occur postprandial; are slower at night; Antiperistaltic waves push cholic content against the normal circuit; Nervous control of colonic motility parasympathetic has stimulatory effect on colic peristalsis; sympathetic produces an inhibition, intrinsic innervation has been identified in the Meissner and Auerbach plexuses. Colon secretion the colon secretes a fluid: ▫ mucus: - Basques; - alkaline ph (ph=8.4); mucus secretion is stimulated by: ▫ direct contact between intestinal contents and glandular cells; ▫ irritation of the colonic mucosa; ▫ of adrenergic stimuli;  the role of secretion: ▫ protecting the colonic mucosa from mechanical and chemical irritation, ▫ to facilitate the passage of feces. NB. No digestive enzymes are secreted in the colon.  Colon absorption the lining of the intestine absorbs: ▫ water; ▫ electrolytes; ▫ vitamins; ▫ ammonium; ▫ bile salts; ▫ urea; ▫ medications (hydrocortisone, morphine);  Vascularization of the colon superior mesenteric artery - branch of the aorta vascularizes: ▪ right colon (cecum, ascending colon); ▪ right half of the transverse colon;  inferior mesenteric artery and sigmoid arteries (superior, middle and inferior); ▪ vasculitizes the rest of the colon; veins accompany the homonymous arteries;  lymph collects: ▪ in a subserosal plexus; ▪ in the lymph nodes: - epicolics; - paracolic; - mesocolic; - intermediaries; - upper or lower mesenteric; Surgical colon pathology Prof. Dr. Dorel Firescu  Colonic diverticulosis ♦ disease most commonly localized to the sigmoid colon; ♦ may affect other colonic segments; ♦ characterized by herniation of the mucosa and submucosa of the colon between the fibers of the circular muscle; ♦ diverticula can be: pulse; false; ♦ sizes are between 1 mm and 7 cm; ♦ number - between a few and several hundred; ♦ affects over 1/3 of the population over 60 years of age; ♦ in 95% of cases the localization is on the sigmoid colon; ♦ complicate with: diverticulitis in 10-15% of cases; lower gastrointestinal bleeding in 20- 30% of cases: - is the most common cause of IHD in the elderly; - in 5% can be severe;  Pathogenesis: ♦ connective tissue degeneration at the intermuscular slits of the colonic wall; ♦ excessive contraction of the circular muscles of the colon; ♦ excessive increase in intraluminal pressure;  Symptomatology ♦ asymptomatic in the vast majority of cases; ♦ in 50% of cases presents: ▪ intermittent pain in the lower hemiabdomen; ▪ abdominal distension; ▪ constipation; ▪ or diarrhea alternating with constipation; ▪ the feeling of abdominal discomfort subsides almost completely after defecation;  Objective ♦ pain on palpation in the iliac fossa and left flank; ♦ Rarely palpate the sigmoid colon unclogged with feces;  Paraclinical explorations ♦ Radiologic examination irigography usually confirms the presence of diverticula; ♦ Endoscopic examination required at the slightest suspicion of colic cancer; or when the source of the lower gastrointestinal bleeding is not deceased; ♦ Selective angiography is the only examination that certifies the diverticulum as the source of the bleeding;  Complications ♦ Lower GI bleeding: ▪ is usually severe; ▪ appears outside other significant charges; ▪ most patients are elderly, with hypertension; Diverticulitis it is due to fecal stasis and involvement of the parietal lymphatic system; constant symptoms are pain and fever; ♦ clinically resembles a "left-sided appendicitis" with: intense pain in the left iliac fossa; fever; chills; increased constipation; abdominal distension; nausea; sometimes urinary symptoms; ♦ objective palpation in the left iliac fossa: ▪ pain; ▪ signs of peritoneal irritation; ▪ kneading; ▪ even local contracture; rectal cough: -Hardness to palpation of the bottom of the Douglas bag.  Complications of diverticulitis ♦ colic fistula: ▪colo-vezicala; ▪colo-vaginal; ▪colo-enteral; ♦ bowel obstruction; ♦ generalized peritonitis ♦ intraabdominal abscesses; Treatment start with medical treatment: digestive rest; antibiotics; analgesic; surgery - after the inflammatory phenomena have subsided. Indications for surgical treatment: 1. diverticulosis in hyperalgic form; ▪ segmental sigmoid resection; 2. lower gastrointestinal hemorrhage; ▪ even if stopped by medical treatment, bleeding will recur in 50% of cases; ▪ segmental resection of the affected area; if the evolution is severe surgery will be done seriously: ♦ colostomy proximal to the affected area; ♦ treating intra-abdominal septic complications - drainage of abscesses or peritonitis; ♦ the second time the colonic resection will be performed;  COLON TUMORS Colonic polyposis ♦ Polyps are generally benign tumors of the large intestine; ♦ addresses any tumor that protrudes into the lumen of the intestine; ♦ can be: ▫ sesili; ▫ pediculate;  Pathology most commonly represented by adenomas which can be: ▪tubular: - small; - darker in color; ▪viloase: - have a broad implantation base, - soft consistency, - with irregular surface. most adenomas are located on: - sigmoid colon; - rect;  polyposis affects older people more often; men are more interested; the risk of malignant transformation of such a tumor increases with increasing size of this polyp; the most prone to malignant transformation are villous adenomas;  Clinic symptoms are absent or erased as long as: ▫ their sizes are small; ▫ have not gotten complicated;  when at least one of the above two conditions has been met: ▪ diarrhea; ▪ mucus leakage (especially in villous tumors); ▪ abdominal colic - when tumors are large and narrow the intestinal lumen; ▪ macroscopic or occult hemorrhage, with or without secondary anemia;  Down located villous adenoma can cause: ▪ severe mucous diarrhea that can sometimes even lead to serious electrolyte disturbances; Paraclinical diagnosis Radiologic examination with contrast and double contrast (irigography) has a considerable percentage of false positives. Rectosigmoidoscopy visualize polyps on the rectum and the last portion of the sigmoid; without being able to visualize the rest of the colon; Colonoscopy is superior to the other two methods; it has the advantage that it is also the means by which one or more polyps can be removed both for therapeutic purposes and to determine whether a malignant transformation has occurred;  Treatment polyps without obvious signs of malignant transformation: ▪ their removal by colonoscopy; polyps: ▪ broad-based implantation; ▪ with obvious signs of malignant degeneration; ▪ as the complicated ones, either with bleeding or intussusception require surgery with segmental colectomy; Other types of polyps are also described polyps that have in their contents: lipoma; leiomyoma; fibroid; neurofibroma; lymphangion, e.t.c.; Polyposis syndromes such as: familial adenomatous polyposis = Gardner syndrome = association of: skin cysts + osteomas + colonic polyposis; - autosomal dominant, juvenile polyposis = Peutz-Jeghers syndrome, which is represented by: -gastrointestinal polyposis + perioral hyperpigmentation, e.t.c.;  ULCERO-HEMORRHAGIC RECTOCOLITIS recognized under other names: ▪ ulcerative colitis; ▪ ulcero-hemorrhagic rectocolitis; ▪ severe ulcerative colitis; Definition: -is a non-specific inflammatory disease, -ulcerative-purulent, -preferably localized in the recto-sigmoid region, -can encompass the entire colon.  most common between 24 - 45 years of age; can occur before the age of 20 or over 50; affects both sexes equally;  Etiopathogenesis is still unknown; several etiologies were hypothesized but remained unconfirmed: ▪ bacterial; ▪ allergic; ▪ immune; ▪ enzymatic;  in the onset and development of the disease some factors are recognized as: ▪ genetic - supported by increased familial incidence; ▪ infectious - important element in the maintenance and development of lesions; ▪ enzymatic - role by removing or digesting protective mucus; ▪ psychosomatic - justified by the existence of conflictual states in the stage preceding the first flare; ▪ immunologic - especially autoimmune mechanisms;  mainly found in the population of economically developed countries: ▪ England; ▪ America; ▪ Scandinavian Tartars; in our country: ▪ frequency is increasing; ▪ forms with severe evolution are more reduced;  is considered a precancerous state for recto-smoid cancer; carcinogenic risk appears after about 10 years;  Pathological anatomy macroscopic findings: ▪ initially mucosa: ▫ hiperemiata; ▫ edema; ▫ with pinpoint hemorrhages; ▪ subsequent ulceration: ▫ of various shapes and sizes; ▫ with hemorrhagic bottom; ▫ then purulent; ▫ very friable mucous membrane; ▫ later on there are reparative processes of sclerosis;  Symptomatology: ♦ knows three clinical forms: benign - localization is only recto- sigmoid; average-most frequent; severe - in which the localization is extensive.  Symptom: ♦ recto-sigmoid syndrome: bloody stools; with mucus and pus; with tenesmus; diarrhea; multiple chairs from 2-3 chairs/day-> to more than 15 imperative shows; pain at and after defecation; permanent anorectal discomfort with burning or stinging sensation; ♦ general phenomena: subfebrile  septic fever sometimes (fever and increased pulse show the severity of the disease); asthenia; depression; anemia; emaciere; sometimes edema; ♦ onset can be: acute; subacute (most common); insidious; ♦ state period symptoms evolve with an aspect of periodicity; the first flare lasts 2 - 3 weeks to 2 - 3 months; then comes a period of relative quiet, only small disturbances; the next attack has a longer duration and more severe symptoms; the quiet period is getting shorter; lulls are increasingly rare and shorter; ♦Clinico-evolutionarily three forms are described: acute fulminant form (5 - 15%); ▪ with dysenteriform febrile onset; ▪ diffuse abdominal pain; ▪ rapid alteration of general condition; ▪ hydro-electrolyte disorders; ▪ malnutrition;  continuous chronic form (5 - 15%), ▪ the symptoms of the acute phase persist but in an attenuated form; chronic intermittent form: ▪ evolves with variable relapses and remissions over time: ▪ is the most common type; ♦objective examination finds: Sabal language; abdomen excavated and tender to palpation; the liver may be enlarged and tender; ♦ Paraclinical explorations: Rectosigmoidoscopy: ▪ is the basic exam; ▪ is made up to 30 cm; ▪ looks: - discharge of mucus, blood and pus; - a particularly fragile mucosa ("mucosa weeps with blood"); - presence of ulcers; - the appearance of a dilated tube; - disappearance of the recto-sigmoid junction; - abscess; - areas of necrosis;  Irigography ▪ decapitate lesions above 30 cm; ▪ can highlight: - abscess; - large ulcers; - short; - withdrawals; - stenosis;  Rectosigmoid biopsy ▪ needs a lot of caution; ▪ is done only when there is a suspicion of cancer; Co-cultures ▪ are done systematically and repeatedly; ▪ underpin antibiotic therapy;  Biological ▪ increased sedimentation rate; ▪ leukocytosis; ▪ hypochromic anemia; ▪ in prolonged forms - hypoproteinemia; ▪ loss of sodium and potassium; ▪ alterations in liver function tests; ♦Evolution ▪ is serious; ▪ with increasingly longer and more pronounced periods; ▪ with casexia and exitus; ♦ Complications can be: ▪ intestinal or extraintestinal, acute or chronic:  Acute intestinal complications ▪ occur especially in severe forms: 1. acute collection - is an enormous and brutal dilation of the bowel; - requires immediate surgery; 2. colon perforation - can be spontaneous or after corticosteroid therapy; - requires emergency surgical treatment; 3. bleeding - can be: large, brutal; - dictates surgical intervention and intensive care;  Chronic intestinal complications ▪ especially in long-term forms: 1. abscesses and fistulas - are very common; 2. stenosis - occurs in almost all cases; 3. cancerization - reported in 4-6% of cases;  Extraintestinal complications are also numerous: ▪ liver; ▪ articular; ▪ cutaneous; ▪ mucous; ▪ ocular; ▪ renal; ▪ rarely cardiovascular; ▪ amyloidosis; ▪ septic conditions; ▪ avitaminoze; ♦Differential diagnosis is made with: ▪ dysentery (bacteriologic examination); ▪ acute and chronic enterocolitis; ▪ muco-membranous rosinopathy; ▪ Nicolas-Favre lymphogranulomatosis; rectal and sigmoid cancer (older age, rectosigmoidoscopy, biopsy, irigography); ♦ Positive diagnosis is based on: ▪ appearance of the seats, ▪ alteration of general condition, ▪ progressive periodicity, ▪ paraclinical examinations, especially rectosigmoidoscopy. Differential diagnostic difficulties also exist with: ▪ internal hemorrhoids; ▪ anal fissures; ▪ Crohn's disease; ♦ Treatment ▪ is very long-term (years); ▪ requires inpatient and outpatient care; Hygiene and diet treatment consists of: ▪ during the evolutionary periods - bed rest and hospitalization; ▪ the rest of the time - mental and physical rest. ▪will remove all irritating foods: -laps, -gluten, -legumes, -rich fruits in cellulose.  Drug treatment. ♦ Symptomatic treatment will consist of: hydro-electrolytic rebalancing, blood and plasma transfusions, infusions with proteolysate, polyvitamins; against pain: ▪ tincture of opium (3 - 4 drops three times/day); ▪ anticholinergics (Lizadon, Bergonal, Pro-Banthine). ♦ Anti-infective treatment is based on repeated coprocult with antibiogram. sulfonamides are preferred at first: ▪salazopyrin-attack doses of 6 - 8 g/24 hours, -decreases gradually to a maintenance dose of 1 - 2 g/day for a long time (6 months to 2 years). -is still trying; ▪sulfaguanidine, ▪ phthalylsulfathiazole. -in patients who do not get results with sulfonamides, antibiotics are prescribed after antibiogram: ▪aminoglucozide, ▪chloramphenicol, ▪tetracycline etc. ▪Corticotherapy gave satisfactory results, with the risk of perforation. -20 mg prednisone/day is recommended, then 10 mg/day for 1-2 months.  Colon cancer is the second leading cause of death after lung cancer; more common in Western Europe and North America; less common in Asia, Africa and South America; affects the 60-70 age group; more of interest to the female sex; Etiology as in all cancers, the etiology is unknown. ; the following elements are considered: -genetic load - inherited aggregated disorders: – ulcerative colitis, – colic polyps, – multiple colic polyposis – Gardner syndrome ; -environmental factors evidenced by the occurrence of cancer in people who have migrated to areas with a high frequency of this lesion; dietary factors: ▫ Favoring factors - animal fats ▫ protective factors - cellulosic fibers (toxin binders) ; the role of bile acids in cancer; Precancerous sties. - Adenomatous polyps -malignant potential -given by size and histologic type. -Villous tumors have an increased risk of malignancy Precancerous inflammatory lesions: -hemorrhagic rectocolitis, -ulcerative colitis Macroscopic anatomopathologic: 1.Cancer vegetant -tumor develops endolumenally, -is bulky -with areas of softening/ intratumoral hemorrhage. -evolves into colon obstruction. 2.Ulcerative cancer -by ischemic necrosis of the tumor =>>> removal of the facets and making a bleeding crater. -evolution of the plant form. -frequently located on the right and transverse colon 3.Schiros cancer (in ferrule) --tumor infiltration retracts circularly the colonic wall -da lumen stenosis. -colic colic-induced, rigid. -have as their seat the sigmoid and the descendant. 4.Mucyocarcinoma is a tumor: -voluminous, -moale, -gelatinous, -hemorrhagic -often infected. 5.Papillary adenocarcinoma. -occurs through malignancy of a villous tumor -and soft, -with friable fringes, -with a wide implantation base, --sometimes with circumferential invasion. 6.Diffuse infiltrative cancer. -rare type of colonic carcinoma, -similar to plastic linnet. -the edges of the tumor are poorly demarcated, -grainy surface with multiple exulcerations. Microscopic -the vast majority of colonic cancers are adenocarcinomas=tumors originating from the glandular columnar epithelium -tumors originating in non-epithelial colonic structures (leiomyosarcoma, lymphosarcoma) < 10%. -we meet:.simple carcinoma (squamous epithelioma).colloid (mucipar) carcinoma.schirul -may have different degrees of differentiation:.well differentiated shapes.poorly differentiatedforms How colon cancer spreads. Direct extension ♦ is progressive; ♦ in the depth and surface of the colonic wall; ♦ circumferential and longitudinal; ♦ invasion and eventual fistulization-in any peritoneal organ;  Lymphatic circulation ♦ in the intraparietal network; ♦ in epicolic, paracolic, intermediate and regional lymph nodes; ♦ ggl invasiveness depends on the degree of malignancy; ♦ anaplastic forms spread more rapidly; ♦ stations are not always traveled in succession;  Hematogenous dissemination ♦ is due: tumor penetration into the colonic veins; entrainment of neoplastic cells in venous blood; ♦ through the portal venous territory => dissemination to the liver; ♦ via lumbar and vertebral veins => in the lung;  Dissemination perinervoasa ♦ occurs along nerves, invading perineural spaces; Intralumenal dissemination ♦ with grafting anywhere on the mucosal surface;  Peritoneal metastases ♦ occur after the tumor has passed the serosa; ♦ neoplastic cells detach and migrate gravitationally into the peritoneal cavity; ♦ is grafted on: -peritoneum, at the bottom of the Douglasbag ♦ another seat is the great epiploon; ♦ in females, nonplastic ovarian insemination is characteristic = Krukenberg tumors; ♦ peritoneal migration leads to: peritoneal carcinomatosis; neoplastic epiploitis; carcinomatous ascites;  Classification-stadialization ♦ Microscopically Dukes and Grinel propose four grades of histologic differentiation of these tumors. The types of classifications are: - DUKES classification; these classifications are confusing; that is why the TNM classification applies;  Dukes classification -initially done for rectal cancer, -In 1939 it was also adopted for large bowel cancer. - underwent several changes, -finally looks like this (Dukes-Coller): - Stage A1: the tumor does not go beyond the mucosa and does not metastasize to the lymph nodes. - Stage- B1. the tumor captures the muscle and does not give lymph node metastases; -B2. the tumor exceeds the muscularis propria but does not metastasize to lymph nodes; - Stage- C1: B1 with regional lymph node metastases; - C2: B2 with distant lymph node metastases. - Stage D: characterizes cases with distant visceral metastases.  Currently the most widely used system for tumor classification is the TNM system proposed by UICC. T = tumor; N = lymph node; M = distant metastasis T = primary tumor -To = primary tumor not detectable; -Tis = carcinoma in situ; -T1 = tumor limited to mucosa or sub-mucosa; -T2 = tumor with muscular or serous extension; -T3 = the tumor extends to adjacent structures or surrounding organs without fistula; -T4 = tumor with manifest fistula; -T5 = T3 or T4 with extension to other organs or tissues beyond the immediately neighboring structures; -Tx = depth of penetration cannot be specified. N - lymphatic nodules No = no evidence of lymph node metastases; N1 = presence of metastases in lymph nodes; Nx = nodule status not known. M = distant metastasis Mo = no distant metastases; M1 = distant metastases.  Stages of colon cancer according to TNM; Non-invasive cancer ♦ stage 0 - cancer in situ, as evidenced by e.g. histopathologic examination Invasive cancer ♦ Stage I - T0-1/N0/M0; T0-1/Nx/M0=A tumor limited to mucosa/submucosa; no metastases in lymph nodes or distant lymph nodes; ♦ Stage II - T2-5/N0/M0; T2-5/Nx/M0 =B the tumor invades the mucosal muscle or goes beyond it, may invade other organs; no demonstrable metastases in lymph nodes or distant lymph nodes; ♦ Stage III - any T/N1/M0=C any tumor invasion of the intestinal wall; with metastases in regional lymph glands; no obvious distant metastases; ♦ Stage IV - anyT/N with M1=D  Classification of colonic cancers by histopathologic differentiation (G1-G4) Broders. ♦ there are 4 types of colon cancers: G1 - high degree of differentiation; G2 - medium degree of differentiation; G3 - low or no differentiation; G4 - degree of differentiation impossible to assess; Varieties of colic cancer Synchronous cancer ♦ is the concurrent development of 2 or more cancers; Metachron cancer ♦ metachronous cancer = the subsequent development of a tumor on the colon after a colonic tumor has been detected/removed; ♦ can occur by insemination (bloody, luminal); ♦ appears 9-11 years after the first surgery; Symptomatology transit disorders : ♦ constipation - progressively installed; - rebellious to treatment with laxatives; - alternating with diarrhea; - in low localizations the stools have a dysenteriform character and can quickly unbalance the patient; ♦ pain - is colicky, - is diffuse in the lower abdomen, - usually starts and ends in the same place; ♦ abdominal rumbling (rumbling) - usually accompany the pain together realizing the Köning syndrome;  Sangerarile: -hidden hemorrhages => anemia -tumors of the cecum and ascending colon, abundant bleeding => melena. -Sigmoid or recto-sigmoid junction tumors may present small amounts of fresh red blood: -rectoagia= red blood mixed with feces or isolated at the beginning of stool -hematochezia =emission of partially digested blood ♦ general clinical signs: - physical and intellectual asthenia; - decreased appetite; - weight loss; - underfebrile or even fever; ♦ Objective we can palpate the tumor or just a puncture site. Particular signs depending on tumor topography Right colon cancer: -The right colon has a wide lumen, thin wall, easily distensible, -content is fluid. -tumors located here are bulky, vegetating, soft, sometimes friable and with necrotic- ulcerated areas="bleeding=" secondary anemia - rarely cause changes in bowel transit. - you may experience progressive constipation or alternating constipation- diarrhea Transverse colon cancer - -most often = bulky, ulcero-vegetative, slightly palpable tumor. -clinically, it frequently presents a borrowing symptomatology due to intimate relations with the stomach, pancreas and gallbladder. -dyspeptic dyspeptic disorders that can be confused with gastroduodenitis, biliary dyskinesia or colitis, -the evolutionary complications of the tumor can be: occlusive, hemorrhage (occult and persistent bleeding), infectious, gastro- colonic or jejuno-colonic fistulas Left colon cancer located on the segment between the left 1/3 of the transverse colon and the rectosigmoid junction. the most common localization of colon cancer, with 75% of colon cancers located in the sigmoid. Tumors located on this segment are usually: – small in volume, – infiltrative, – circumferential and stenosing, – clinical manifestations are dominated by disorders of bowel transit. – feces may contain streaks of blood or mucus. – in low localizations, pencil-shaped chairs appear.  Paraclinical diagnosis ♦ Hematology tests ▪ hypochromic anemia; ▪ hypoproteinemia; ▪ High VSH; ▪ leukocytosis; ♦ Irigography ▪ gives correct results 90% of the time; ▪ show: - gap; - stenosis; - the look of apple or golf pants; - complete stop in occlusive forms; ♦ Rectocolonoscopy: rectoscopy can visualize tumors on the distal sigmoid; colonoscopy can highlight tumors throughout the colic; allows at the same time the collection of fragments for histopathologic examination; ♦Abdominal ultrasound : can highlight: - tumor; - peritoneal and liver metastases; - presence of ascites; -cannot pinpoint the exact organ; ♦Computed tomography and magnetic resonance imaging are superior to ultrasound, allowing a finer diagnosis. ♦ Carcinoembryonic antigen assay has neither disease nor organ specificity; is important only for postoperative follow- up of patients; ♦ Urography, pulmonary radiography, skeletal radiography as well as bone scintigraphy have a role in preoperative workup of such a patient.  Progress and complications without treatment the condition rapidly progresses to complications; The smaller the lumen of the bowel segment, the higher the rate of complications;  the most common complications are : ▪ occlusion; ▪ hemorrhage; ▪ perforation with generalized peritonitis; ▪ peritoneal carcinomatosis with ascites; ▪ compression of neighboring organs;  Treatment is mainly surgical; type of operations practiced depending on: ▪ type of intervention: - on an emergency basis; - planned intervention ▪ degree of local extension of the lesion; ▪ presence of metastases; ▪ age and general condition of the patient, e.t.c.;  rigorous preoperative preparation of these patients is required for scheduled surgery; ♦ general - combating: ▪ anemia; ▪ hypoproteinemia; ▪ hydroelectrolyte imbalances; ▪ treatment of associated diseases; ♦ local: ▪ mechanical preparation of the colon by: - diet; - laxative: saline solutions, mannitol solution, Fortrans; ▪ antimicrobial treatment to reduce colonic microbial flora;  operations can be: ▪ Paleative: - limited segmental colectomy; - internal derivation of type: ◦ ileo-coloanastomosis; ◦ colo-coloanastomosis; - type stoma: ◦ cecostomy; ◦ iliac anus; ▪ oncologic surgeries: - go to: ◦ lesion removal within oncologic safe limits; ◦ along with vessels and ganglionic stations; ◦ as an example: - right hemicolectomy; - left hemicolectomy; - transverse colectomy;  Ano-rectal surgical pathology Elements of anatomy The rectangle represents: - the last portion of the digestive tract; - about 15-25 cm long; - extends from the third sacral vertebra (S3) to the anocutaneous line.. - on its way describes several curves, both in the frontal and sagittal planes; - It starts at the rectosigmoid junction, which is the peritoneal portion of the rectum, continues with the rectal ampulla, then the recto-anal junction and finally the anal canal;  Peritoneal portion - 2 to 7 cm long; - it is covered by peritoneum, only on the anterior and lateral sides, posteriorly starting from the mesorectum where the superior hemorrhoidal artery, the terminal branch of the inferior mesentery, bifurcates;  Rectal vault - stretches up to the anus-rectal junction about 12-15 cm long; - is the most dilated portion of the rectum - by its anterior face covered by the pelvic parietal peritoneum, it participates in the formation of the Douglas pouch. - in men it has anterior relationships through the recto-vesical fascia Denonvilliers, with the bladder, seminal vesicles, vas deferens and prostate; The veins and nerves of the rectum form the middle rectal pedicle or lateral rectal wings. The recto-anal junction - is where the ampullar rectum passes into the perineal rectum; - marked on the inside by 8-10 vertical folds, 1-1.5 cm high, formed by the mucosa and called Morgagni columns; Perineal rectum or anal canal - about 3 cm tall; - is the terminal portion of the digestive tract in which the mucosa becomes initially cuboid and then squamous, with a cutaneous character. The anal canal is described as the Morgagni sinuses: - are folds of mucous like swallow's nests; - arranged between the Morgagni columns together with which it realizes the pecten, a toothed line, under which the white intersphincteric Hilton line is palpated.  The anus has a sphincter: - proximally placed internal and a - distally arranged external sphincter. The anal sphincter complex is also made up of the anal levator muscles, which make up most of the pelvic diaphragm. Arterial vascularization is achieved by: a. superior hemoroid - terminal branch of the lower mesenteric; a. medium hemoroid - branch of the hypogastric artery; a. lower hemorrhoidal - ram from the internal hemorrhoids; a. middle sac - branch of the posterior wall of the aorta. The veins form three plexiform hemeoroidal networks: superior, middle and inferior, linking the port and cav cav system. Hemorrhoids Definition - varicose dilatations of one or more veins belonging to the hemorrhoid plexus. They can be: ♦ internal hemorrhoids, involving the internal hemorrhoid plexus and located within the anal canal; ♦ External hemorrhoids developed in the external hemorrhoid plexus and evident below the cutaneo-mucous line, outside the anal canal; ♦ mixed hemorrhoids, which combine the first two variants;  Etiopathogenesis. They are more commonly found : - in men; - around the age of 40; Most common: - are associated with general collagen disease, which links them in association with hydrostatic varicose veins, flat feet, varicoceles and hernias;  As a predisposing factor - the bipedal position, which leads to increased hydrostatic pressure in the inferior venous cav system. Also under predisposing factors are cited all causes of hypertension of the lower cav system: - prolonged orthostasis; - chronic constipation; - HTP; - chronic bronchitis; - heart failure; - pelvic tumors, e.t.c.;  They can't be omitted either: - hereditary elements; - prolonged sedentarism; Pathology - varicose dilatations involving the submucosal venous plexus showing abnormal laxity of the submucosal connective tissue; - dilatations favored by the absence of valves in the hemorrhoidal veins and consequently the hypertension in the port system is reflected downward at this level;  Four grades of these hemorrhoids are described: ♦ Grade I - hemorrhoidal bursules at the pectineal line; ♦ grade II - hemorrhoids present in the anal canal during defecation; ♦ grade III - the hemorrhoid prolapses outward during defecation;