SAGES Case of the Month: Presentation
Submitted by Steven D. Wexner, MD
Minimally-invasive approach to low rectal adenocarcinoma -
Cleveland Clinic Florida
A 45 year old male with no significant past medical or surgical history presented with occasional rectal bleeding following bowel movements. He denied any change in bowel habits or caliber of his stools. He denied weight loss or other systemic symptoms.
Upon presentation, he was hemodynamically normal and the physical examination was unremarkable except for the rectal exam. This revealed a 3cm mobile ulcerated mass approximately 2cm proximal to the dentate line in the anterolateral quadrant.
Colonoscopy was performed to the cecum, which revealed only the ulcerated mass in the lower rectum. Biopsy was positive for adenocarcinoma.
He received neoadjuvant chemoradiation with Xeloda for 6 weeks, followed by surgery 6 weeks after completion of treatment. Routine preoperative workup was perfomed, along with anal manometry and preoperative bilateral stoma site marking.
He underwent a laparoscopic restorative proctectomy with hand-sewn transperineal colonic J-pouch reconstruction and diverting loop ileostomy. He had preoperative placement of bilateral ureteral stents which were removed at the completion of the operation. He received a diverting loop ileostomy in the right lower quadrant, along with a drain in the pelvis.
Pathology revealed a microscopic focus of residual adenocarcinoma involving the muscularis propria, no vascular or perineural invasion and 1 out of 11 positive lymph nodes. The distal margin was 1.4cm and the circumferential margin was 22mm and both were free of tumor. The stage was ypT2N1Mx.
His postoperative course was uneventful and he was discharged on postoperative day 4. He was seen in followup 6 weeks later and reported having started chemotherapy. He will undergo reversal of the loop ileostomy after completion of chemotherapy.
