Transanal Protocol PDF

Presentor: Arvin Paulo S. Aquino M.D.
AMD: Armando Crisostomo M.D., FPCS,

Moderator: Alvis Sarte, M.D., FPCS
GENERAL DATA:
VR, is a 75 year old, female, Filipino, Roman Catholic, from Pasig City, was admitted on the 10 th of March 2018.
CHIEF COMPLAINT: Decrease caliber of stool
HISTORY OF PRESENT ILLNESS:
7 months prior to admission, patient noted change in stool noted to be decreased in caliber presented goat stool like
associated with pain in defecation. It was non- bloody and mucoid in character.
5 month prior to admission, the decreased in stool caliber persisted, but with noted blood and mucoid in stool, there were
no other associated sign and symptoms
A month prior to admission, due to persistence of symptoms, patient sought consult. Colonoscopy was done and noted a
flat polyp (dia < 0.3 CM ) was seen and removed with a biopsy forcep at 80cm level. And a polypoid bilobed 3.6 in length at the
anorectal area (5cm from the anal verge) biopsy result was adenomatous polyp with dysplasia fragments and adenocarcinoma well
differenciated
Two weeks PTA, CT scan was done and reveal an irregular anorectal wall mass with associated surrounding fat stranding
projecting intraluminally measuring 3.3 x 2.1 x 1.7 cm approximately 3.5 cm from the anal verge. Mesorectal fascia is intact. It was
signed out as Irregular anorectal wall mass projecting intraluminally, consider neoplastic process.
She was advised surgery hence admission.
PAST MEDICAL HISTORY: (+) HTN > 10 years , Atrial fibrillation (+) DM TYPE II
PREVIOUS SURGERY: s/p open cholecystectomy ( 1975)
s/p hemorrhoidectomy ( 1982)
s/p colonoscopy with biopsy (feb 2018)
FAMILY HISTORY: (+) DM – maternal (-) HTN, Thyroid disease, CA

PERSONAL AND SOCIAL HISTORY: Non-smoker, occasional alcoholic beverage drinker,
REVIEW OF SYSTEMS:
General : no loss of appetite, no weight loss/gain
Skin : no skin dryness, no rashes
HEENT : no aural discharge, no nasal discharge, no abnormal lacrimation, no tinnitus
Cardiovascular : no cyanosis, no easy fatigability
Respiratory : no dyspnea, no colds, no cough
Genitourinary : no hematuria, no frequency, no oliguria
Endocrine : no polydipsia, no polyphagia no polyuria, no heat or cold intolerance
Musculoskeletal : no joint stiffness, no limitation of motion
Neurologic : no weakness, no headache, no seizures
PHYSICAL EXAMINATION:
GENERAL : awake, coherent, not in CP distress, ambulatory
VITAL SIGNS : BP: 130/80 HR 60 RR 20 T 36.5C
ANTHROPOMETRIC : Weight: 57.6kg Height: cm BMI:
SKIN : warm skin, jaundiced, no rashes
HEAD : no masses, no swelling, no characteristic fascies
EYES :anicteric sclerae, pupils 2-3mm ERTL, pink palpebral conjunctivae
EARS : no discharge, no tragal tenderness, non-hyperemic external auditory canal
NOSE : patent nares, nasal septum midline, no discharge
MOUTH : pink lips, moist oral mucosa, non hyperemic post. pharyngeal wall
NECK : supple neck, no masses, no cervical lymphadenopathy
CHEST : symmetrical chest expansion, no retractions, clear breath sounds
HEART : adynamic precordium, normal rate, regular rhythm, no murmur
GIT : soft, non-tender non-distended, normoactive bowel sounds, soft,(-) Murphy’s
RECTAL : (+) intact rectal vault, tight sphincteric tone, polypoid rectal mass, soft non-tender, about 3cm in
Widest diameter , 4-5 cm from the anal verge, with blood on the examining rectal finger
GENITALIA : grossly normal
EXTREMITIES : pulses full and equal, no edema, no cyanosis, no erythema
ADMITTING IMPRESSION: Rectal adenocarcinoma stage III s/p colonoscopy (Feb 2018)
OPERATIVE PROCEDURE: transanal excision
COURSE IN THE WARDS:
Upon admission, patient was put on liquid diet, vital signs were monitored. Several examinations was done as out patient. Bowel
preparation and medication was started. Bowel preparations as follows: may have light breakfast, no lunch no dinner. May have lots
of clear liquids till 12 midnight. Dulcolax 2 tabs at 1pm. And another 2 tablet at 6 pm. PEG (surelax) 10 sachet in 2 liters of water to
be consumed at 2-5 pm. NPO from midnight. Patient was cleared from medical stand point was scheduled to transanal excision of
rectal mass.
On the third hospital day, She underwent trans anal excision of rectal mass. and tolerated the procedure well.
Post- operatively, vital signs were stable and medications were continued.
Day 1 post op, patient was comfortable with minimal post-op pain (+) flatus but no urge to defacate. Anal pack was removed, hot
sitz bath was started for 15 minutes TID and patient was started on clear liquids and foley catheter was removed as well.
Day 2 post-op, patient is still comfortable with minimal post op pain, she had flatus and bowel movement no bleeding on the post-
op site and now on general liquids.
Day 3 post-op, patient was placed on soft diet. She had multiple flatus, no bowel movement, tolerated the soft diet and post-op
pain. rest of hospital stay was uneventful.
Patient was also discharged on the same day.

DIAGNOSTICS:
Bleeding Parameters
CBC Clinical Chemistries Feb 20
Hgb 121 Coagulation time :Lee White
Creatinine 97
Hct 0.38 Bleeding Time: Surgicut
Sodium 133.7
WBC 5.9 Potassium 4.05 Prothrombin Time 12.9
Seg 66 CEA 4.24 Control 13.2
Lym 30 INR 0.93
Mono 4 Protime Activity 109
Plt 236
Chest X-ray: Suspicious opacities, Right upper lobe, cardiomegaly ; AA
ECG:
Atrial fibrillation in slow ventricular response; LAD
Surgical histopathologic result feb 06

Clinical diagnosis: hematochezia ; colonic polyp; colonic diverticle; anorectal mass r/o malignancy
Operation: colonoscopy
Specimen: (A) polyp 80cm level; (B) anorectal mass
Histopathologic diagnosis:
(A) Adenomatous polyp with dysplasia in fragments
(B) Adenocarcinoma , well differentiated
Gross description:
Specimen received in formalin consist of two parts
The first, designated as “polyp 80 cm “ consist of two gray tan irregular rubbery pieces of tissue each measuring 0.4 x 2.0 x 2.0 cm. all
tissue are labeled as A
The second, designated as “anorectal mass “ consist of 4 gray tan, irregular rubbery pieces of tissue ranging from 0.2 x0.1x0.1 cm all
tissue are labeled as B
Surgical pathology result ( 3/ 11/ 2018)
Rectal mass (transanal excision)
Adenocarcinoma, moderately differentiated, ( rectal mass) with muscle involvement
Remarks :
Tissues are received in fragments and cannot assess for margins. This case was seen by Dr. Alsol and Dr. Dela Fuente who concurred
with the above diagnosis
Description gross:
Specimen received in formalin designated as rectal mass, consist of several, tan- brown. Irregular, rubbery tissue fragments
measuring 4.5 x 3. 2.3 cm in aggregates and ranges from 0.5 x 4x 0.3 cm to 4 x 3x 1cm. the outer surface are coarsely granular.
Section show too granular cut surface.
OR FINDINGS: 3/11/18)
 Patient on jackknife position under spinal anesthesia
 Asepsis and anti sepsis done
 Sterile drapes places
 Lone star retractor places and anal mucosa viewed
 4 stay sutures placed at edges of the mass
 Mass excised ( full thickness) of rectum using electrocautery
 Anastomosis done using vicryl 2-0, simple interrupted
 Hemostasis/ washing
 Sterile dressing
 End of procedure
Patient tolerated the procedure well
Findings : (+) soft, sessile, locular mass located 3-4 cm from the anal verge mass measures – 2cm in widest diameter and 3 cm in
length located anteriorly
CT SCAN AND COLONOSCOPY
Colonoscopy Feb 6
a flat polyp (dia < 0.3 CM) was seen and removed with a biopsy forcep at 80cm level. A small diverticle was also noted. There was a
polypoid bilobed mass (3.6 cm in length) noted at the anorectal area ( 5cm from the anal verge )
CT SCAN whole abdomen with contrast march 7

Multiple CT images of the whole abdomen with oral rectal IV contrast were obtained. No untoward reaction was noted.
CT images of the whole abdomen reveal an irregular anorectal wall mass with associated surrounding fat stranding projecting
intraluminally measuring 3.3 x 2.1 x 1.7 cm approximately 3.5 cm from the anal verge. Mesorectal fascia is intact
Subcentimeter to prominent para rectal lymph node are seen with sizes ranging from 0.6 cm to 1cm
The liver and spleen are normal in size with scattered parenchymal calcifications and pancreas are normal in size an tissue
homogenenicity. There are no focal masses noted within.
The gall bladder is normal in size and appearance with no evident lithiasis noted
The kidney showed good excretory function are normal of size position and configuration.
The urinary collecting structures and urinary bladder are normal
The medial limb of the left adrenal gland is prominent measuring 0.6 cm with hypodense focus measuring 0.5 cm
The right adrenal presents with normal size and position with normally developed crura. The adrenal compartment is unremarkable.
Wall calcification are seen along the abdominal aorta and both iliac vessels. Degenerative changes are noted at the margins of the
thoracolumbar spine. Grade 1 retrolisthesis of L2 over L3 and anterolisthesis of L4 over L5 are noted.
The rest of the soft tissue are unremarkable
Incidental finding of linear density in the posterior segment of the right lower lobe is noted.
1. Irregular anorectal wall mass projecting intraluminally, consider neoplastic process.
2. Subcentimeter to prominent pararectal lymphnodes
3. Hepatic and splenic calcifications
4. Prominent left adrenal gland with hypodense focus in medial limb, consider adenoma
5. Atheromatous abdominal aorta and iliac vessel
6. Osteodegenerative changes, thoracolumbar spine with listhesis L2 over L3 and L4 over L5
7. Subsegmental atelectasis right lower lobe

Transanal Protocol PDF

Uploaded by

Copyright:

Available Formats

Transanal Protocol PDF

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Transanal Protocol PDF

Uploaded by

Copyright:

Available Formats

Presentor: Arvin Paulo S. Aquino M.D.

AMD: Armando Crisostomo M.D., FPCS,

FAMILY HISTORY: (+) DM – maternal (-) HTN, Thyroid disease, CA

Patient was also discharged on the same day.

Surgical histopathologic result feb 06

CT SCAN whole abdomen with contrast march 7

You might also like