One of the series of popular science articles on rectal cancer: cutting the tumor and protecting the anus
The article was published in the 11th issue of "Popular Health" magazine, 2009
Zhang Mochuan, a cadre of a state-owned enterprise, is in his forties and has a title of "Boss" in his work. On the one hand, the reason for this name is that he works hard and never asks for leave. In addition, he thinks that he is physically strong. With the energy of "slightly injured but not below the line of fire", he is very appreciated by the leaders. Another reason is that he has an amazing amount of alcohol and a bold personality. He belongs to the kind of master who can drink two to two and one catty, so he is also very popular with customers and colleagues. However, Lao Zhang himself had a small problem. He had diarrhea after drinking, and he often had "hemorrhoids", sometimes he would have blood in the stool, and his weight had dropped a lot during the year. But Lao Zhang thinks that liquor hurts the stomach and diarrhea is a normal thing. After the diarrhea, it is equivalent to removing all the "toxins" from the body. Blood in the stool is a chronic problem for many years. Eating hot peppers or drinking alcohol can heal himself in a few days. . Of course it doesn’t matter to be thinner, as the age is gradually getting older. As the saying goes, it’s a good thing for a daughter to buy old and thin.
Until one day in 2006, Lao Zhang finished drinking as usual and felt as if he had a diarrhea, but this time he couldn’t get it out, and his stomach hurts more and more. At first he could bear it, but Zhang thought he could bear it. I was able to pass, and I still insisted on going to work the next day. Later, my stomach was very distended, I kept sweating in pain, and my body temperature started to rise. After the persuasion of colleagues and leaders, I came to the emergency department of the hospital. When I arrived at the hospital, my body temperature had risen to 39.0 degrees Celsius, white blood cells were 15.94×109/L (normal value 4-10×109/L), and there was anemia. Lao Zhang was quickly diagnosed as acute intestinal obstruction. In order to determine the cause of intestinal obstruction, the doctor recommended abdominal CT. But the test results shocked everyone at once, Lao Zhang is suffering from rectal cancer! Moreover, cancer cells have invaded the surrounding tissues, which means that Lao Zhang’s rectal cancer is likely to be in the middle and advanced stages. Under normal circumstances, it takes about 18 to 24 months for rectal cancer to grow and infiltrate the intestinal wall for 1 week, and the time when Lao Zhang began to appear blood in the stool and weight loss did basically coincide with this time!
Although Lao Zhang and his colleagues could hardly believe such a cruel reality, they knew in their hearts that this disease must be operated quickly. But the doctors didn't seem to be in a hurry. After placing a gastric tube for Lao Zhang, the doctors and family members reported the condition and suggested that Lao Zhang should be treated conservatively temporarily. If the obstruction symptoms get worse, emergency surgery is needed.
This in the end is why? Because the main function of the colon is to absorb water and electrolytes, form, store and excrete stool. Lao Zhang’s tumor is located in the sigmoid colon. Due to the high content of bacteria in the stool, emergency surgery cannot complete the preparations such as intestinal cleaning. Therefore, the healthy intestine can not be sutured directly after the tumor is removed. A temporary "artificial anus" is required, which is made in the abdomen. An opening to collect excrement, cover the stoma with a special bag and collect excrement. The stoma was closed again after 3 months. If the obstructive symptoms are relieved by conservative treatment, the intestine can be anastomosed directly with sufficient preparation, so that unnecessary secondary operations can be avoided.
The length of the colon is about 1.5m-2.0m. According to its position, from right to left, it is ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and rectum is the intestine within 13-18cm from the anus.
Three-dimensional reconstruction of the colon, the upper rectum is obviously narrow
It takes about 18 months for rectal cancer to grow and invade the intestinal wall for a week. CT shows that Lao Zhang’s rectal cancer has invaded the surrounding normal tissues.
Fortunately, rectal cancer did not completely block the intestinal cavity. After a few days of conservative treatment, Lao Zhang’s intestinal obstruction was relieved. After careful preparations for intestinal cleaning, Lao Zhang underwent surgery. The name of the operation is anterior rectal resection, which is all performed in the abdominal cavity. Because the lower edge of the tumor is far away from the anus, radical resection will not damage the function of the anal sphincter, so the old anus can be preserved. If the location of the tumor is closer to the anus, in order to ensure the radical resection of the tumor, it is necessary to remove the anus for a permanent stoma.
The doctor enters the abdominal cavity through a longitudinal incision below the belly button. First, a comprehensive examination of the abdominal cavity is carried out to determine whether there are metastases. At the same time, the surgical resection scope is again determined and the difficulties that may be encountered in the operation are estimated. Rectal cancer can infiltrate and grow to the upper and lower ends of the bowel, but most patients will not spread down more than 3cm. Therefore, the tumor can be completely removed by removing the 3cm bowel tube under the tumor.
When the intestinal tube is removed, gauze tape is generally used to tie the intestinal cavity at both ends of the tumor to prevent the tumor from spreading in the intestinal cavity. When the intestine is removed, the corresponding mesangium must be removed. There are arteries, veins, fat, and lymph nodes that supply the intestine in the mesangium. Complete removal of the mesorectum will also clean up the lymph nodes that may metastasize.
The separation of the lower end of the intestine is carried out in a special gap. The front of this gap is the seminal vesicle gland and the prostate. The loose tissue gap at the back contains the presacral venous plexus. Since most of the veins pass through the bone holes on the sacrum, After the injury, the vertebral veins will retract into the intervertebral foraminal bone, making it difficult to clamp the bleeding. Therefore, the amount of bleeding is large, which may lead to hemorrhagic shock and even death in a short time, so it has become one of the extremely dangerous complications in rectal cancer surgery. Although Lao Zhang’s rectal cancer has invaded this structure, fortunately, the doctors used the correct method of hemostasis in time during the operation. They used a pushpin made of titanium-nickel alloy to press the bleeding point, and the original was controlled in just a few minutes. Possible heavy bleeding.
Tumor invades the entire thickness of the intestinal wall
Lymph nodes around tumor
After the tumor is removed, the upper and lower intestinal tubes need to be re-anastomosed. At present, staplers are generally used. The stapler is an extension of the doctor's surgical technique, which can suture the intestine more evenly and firmly, and greatly shorten the operation time.
After the operation, Lao Zhang recovered very smoothly, but after all, the tumor was discovered too late. Postoperative pathological examination confirmed that the intestinal tube had invaded the surrounding tissues and most of the surrounding lymph nodes had also metastasized. Lao Zhang belonged to the latest clinical stage IV patient. A large number of medical statistics show that tumor staging and prognosis are closely related. The five-year survival rate of stage I patients with early stage can be as high as 90%, and the prognosis of stage IV is the worst, with a five-year survival rate of only about 18%. Lao Zhang received chemotherapy, radiotherapy, and biological immunotherapy after surgery. In April this year, Lao Zhang’s tumor metastasized to the lungs and liver. He started receiving systemic chemotherapy again and is still fighting stubbornly with the tumor. When I saw him a few days ago, although he looked a little thin and tired, he He still confidently said: I am not too demanding now. It seems to be difficult to completely eliminate him, but I hope to coexist with my rectal cancer!
Schematic diagram of stapler anastomosing intestine