Treatment
(a) Surgical treatment is divided into two types: radical and palliative.
1.Radical surgery. Surgery can certainly remove the cancer, but there are still residual cancer, or regional lymph node metastasis, or the presence of cancer thrombus in blood vessels, etc. The chance of recurrence and metastasis is very high. The surgical method depends on the location of the cancer in the rectum. There are two systems of submucosal lymphatic plexus and intermuscular lymphatic plexus in the rectal wall, and metastasis of cancer cells in the lymphatic system in the intestinal wall is not common. Once the cancer cells penetrate the intestinal wall, they spread to the lymphatic system outside the intestinal wall. Generally, the parametrial lymph nodes at the same level or slightly above the cancer are involved first, and then the intermediate lymph node group accompanying the superior hemorrhoidal artery is gradually involved upward, and finally the parametrial lymph node group of the inferior mesenteric artery. The above lymphatic metastasis to the upper part of the rectum is the most common metastasis mode of rectal cancer. If the cancer is located in the lower part of the rectum, the cancer cells can also invade the closed lymph nodes laterally along the lymphatic vessels of the anal raphe and the fascial surface of the pelvic wall, or flow along the middle hemorrhoidal artery to the internal iliac lymph nodes. Sometimes, cancer cells can also pass downward through the anal raphe and drain along the inferior hemorrhoidal artery to the lymph nodes in the sciatic rectal fossa and inguinal lymph nodes. Since the direction of lymphatic metastasis of upper rectal cancer is almost always upward, surgery to remove the lymphatic tissues adjacent to the cancer and above this plane can achieve the purpose of radical treatment, and surgery may preserve the anal sphincter. Although the lymphatic metastasis of lower rectal cancer is mainly upward, there is also the possibility of lateral metastasis to internal iliac lymph nodes and closed-hole lymph nodes.
(1) Combined transabdominal perineal resection (miles surgery): It is suitable for cancer of the lower rectum less than 7 cm from the anal verge, and the scope of resection includes the sigmoid colon and its mesentery, rectum, anal canal, anal raphe, tissues in the colorectal fossa and skin around the anus, and the blood vessels are ligated and cut at the root of the inferior mesenteric artery or below the left colonic artery division, and the corresponding para-arterial lymph nodes are cleared. A permanent colostomy (artificial anus) is made in the abdomen, and the perineal wound is closed in one stage or stuffed with gauze. This procedure has a complete resection and high cure rate
(2) Transabdominal low resection and extraperitoneal one-stage anastomosis, also called anterolateral resection of rectal cancer (dixon surgery), is applicable to upper rectal cancer that is more than 12 cm from the anal verge, in which the sigmoid colon and most of the rectum are resected in the abdominal cavity, the rectum below the peritoneal reflex is freed, and the sigmoid colon and the rectum are anastomosed extraperitoneally. This operation is less damaging and can preserve the original anus, which is more ideal. If the cancer is large in size and has infiltrated the surrounding tissues, it is not suitable.
(3) Rectal cancer resection with preservation of anal sphincter: it is suitable for early rectal cancer of 7-11 cm from the anal verge. If the cancer is large and poorly differentiated, or if the main lymphatic vessels upward have been obstructed by cancer cells and there are transverse lymphatic vessels metastasis, the resection by this surgical method is not complete, and transabdominal perineal colectomy is still better. The existing anastomosis for rectal cancer with preserved anal sphincter includes anastomosis by anastomosis, transabdominal low resection – transanal exenteration anastomosis, transabdominal free – transanal drag-out resection anastomosis, and transabdominal transsacral resection, etc., which can be chosen according to specific conditions.
2.Palliative surgery. If the local infiltration of the cancer is serious or the metastasis is extensive and cannot be cured, in order to relieve the obstruction and reduce the patient’s pain, palliative resection is feasible by making limited resection of the intestinal segment with cancer, sewing up the distal rectum and taking the sigmoid colon for stoma (hartmann surgery). If this is not possible, only sigmoidostomy is performed, especially in patients with intestinal obstruction.
(ii) Chemotherapy
About half of the patients with rectal cancer develop metastasis and recurrence after surgery. Except for some early stage patients, patients with advanced stage and after surgical resection need to receive chemotherapy. Chemotherapy is another important treatment measure in the comprehensive treatment of rectal cancer after surgical treatment. Chemotherapy will inhibit the bone marrow hematopoietic system, mainly the decline of white blood cells and platelets, so as to make up for the shortage of chemotherapy and reduce the damage of chemotherapy on hematopoietic system
(iii) Radiation therapy. The status of radiotherapy in the treatment of rectal cancer has been paid more and more attention, and there are two kinds of comprehensive treatment combined with surgery and traditional Chinese medicine and simple radiotherapy.
1.Comprehensive treatment combining surgery, traditional Chinese medicine and radiotherapy
① Preoperative radiotherapy can control primary lesions, control lymph node metastasis, improve resection rate and reduce local recurrence, and is applicable to stage III (dukesc level) rectal cancer. Adopting anterior and posterior pelvic two-field counter-irradiation with radiation dose up to 40~45gy (4000~4500rad), and surgery 3 weeks after radiotherapy.
②Postoperative radiotherapy is suitable for lesions with lymph node metastasis confirmed by pathological examination, cancer that has significantly infiltrated outside the intestinal wall, and residual unresectable lesions in the pelvis. Generally, it starts 1~2 months after the perineal wound has been healed, and the anterior and posterior pelvic fields are irradiated, sometimes the perineal field is also irradiated, and the radiation dose can be 45~50gy (4500~5000rad).
(D) Chinese medicine treatment a large number of clinical practice has proved that high-dose radiotherapy and chemotherapy for patients in the middle and late stages, or chemotherapy again for patients who have developed drug resistance can only lead to a weakened life more critical, accelerating the death of patients. It is often seen clinically that the cause of death of patients is not caused by cancer itself, but due to unscientific and inappropriate lethal treatment. For example, liver failure such as ascites and jaundice after multiple interventions for liver cancer leads to death; lung cancer causes respiratory failure and death after chemotherapy for pleural fluid; nausea and vomiting after chemotherapy for gastric cancer and intestinal cancer lead to more exhaustion and death of patients; white blood cells drop and patients die from infection, etc. Traditional Chinese medicine for cancer treatment can reduce patients’ symptoms and pain, improve the quality of survival, prolong life and reduce the mortality of cancer.
What are the commonly used rectal cancer surgery methods?
Commonly used surgical methods for rectal cancer can be divided into two categories: anus-preserving and non-anus-preserving surgery. First of all, we will introduce the commonly used anus-preserving surgical methods in clinical practice. This type of surgery is more often used in the hope of making anastomosis of the colon and rectum after resection of rectal tumor, especially for low rectal cancer, which is especially important.
(1) Transabdominal rectal pre-cancer resection (Dixon operation) resection scope: this operation requires resection of long enough sigmoid colon and rectum, and clearance of corresponding tissues and surrounding tissues of the mesentery and corresponding lymph nodes. After resection, an end-to-end anastomosis of the colon and rectum is performed. The anastomosis can be performed with the aid of an anastomosis clutch if the anastomosis level is low. This procedure allows preservation of the anus and is ideal if the resection is complete.
(2) combined perineal resection with preservation of anal sphincter (Bacon operation) differs from Miles operation in that the perineum is cut off at the dentate line, the anal sphincter and surrounding tissues are preserved, and the severed end of the colon after resection of the tumor is dragged out from the perineum and sutured to the cut edge of the skin, this operation preserves the sphincter, but the defecation reflex is poor and the perineal resection is not complete, so it is suitable for middle rectal cancer. Such as extraperitoneal overlapping anastomosis, external anal retraction out anastomosis, and transabdominal free presacral anastomosis, etc. In recent years, due to the application of anastomosis, low-level colon and rectal anastomosis has become more convenient, and except for certain special cases, the above-mentioned procedures are rarely used.
(3) combined abdominal perineal proctocolectomy (Miles procedure): the resection scope of this procedure includes part of the sigmoid colon, all of the rectum, the lymph nodes around the inferior mesenteric artery, the levator muscle, the sciatic rectal fossa tissue, the 5 cm diameter skin around the anus and the anal canal, and the sphincter muscle. The resected posterior colonic section was made into a permanent artificial anus in the abdomen, and the perineal wound was closed with sutures. The operation is performed transabdominally and the abdominal perineum is operated simultaneously. The advantage of the operation is that the resection is complete, the disadvantage of the large trauma, permanent artificial anus brings inconvenience to life. Therefore, in recent years, some people have designed surgical methods such as femoral thin muscle instead of sphincter, colonic muscle tube instead of internal sphincter, colonic sleeve, and anterior sacral colon into angle, trying to set the artificial anus at the perineal incision with the removal of the anus and sphincter, which has certain effect but the ability to control defecation still has some difference.
Complications of radiotherapy for rectal cancer
Complications of radiotherapy include local injury and systemic injury. Local injuries include radiation dermatitis, radiation enteritis, radiation osteitis, etc.; systemic injuries include digestive system reaction and bone marrow suppression.
1.Local injury.
①radioactive dermatitis: at the early stage of radiation, the skin is red and itchy, similar to sunburn dermatitis changes; in the middle of radiation, skin pigmentation, thickening and roughness, thick and black pores; in the late stage of radiation, wet peeling can occur in the skin folds and groin area, local skin swelling, and in severe cases, blisters, followed by rupture, erosion, and even ulcers.
②Radiation enteritis: in the middle and late stages of radiation, patients can feel abdominal discomfort, which is aggravated after eating or drinking, and intestinal obstruction can occur in severe cases. This is due to mucosal congestion and edema of the intestine under radiation damage.
(iii) Soft tissue fibrosis: appears in the late stage of radiation, often manifesting as local tissue hardening and loss of the elasticity of normal tissue.
2.Systemic adverse reactions.
①Gastrointestinal reactions: patients often have dry mouth and dry stools at the beginning of radiotherapy; in the middle and late stages of radiotherapy, patients may suffer from loss of appetite, nausea and vomiting.
②Myelosuppression: it mostly occurs in the late stage of radiotherapy, manifested as general weakness, and the total number of white blood cells (WBC) is found to decrease in hematological examination.
Indications for rectal cancer radiotherapy.
Rectal cancer cells are moderately sensitive to radiation killing, therefore, radiotherapy is often used as one of the integrated methods in the treatment of rectal cancer, together with surgery and chemotherapy, in order to achieve the purpose of radical cure. Radiotherapy in rectal cancer treatment is applicable to several aspects: preoperative radiotherapy, intraoperative radiotherapy, postoperative radiotherapy, palliative radiotherapy, treatment of metastatic cancer, etc.
1.Preoperative treatment: Preoperative radiotherapy can reduce intraoperative tumor implantation and the incidence of postoperative pelvic small bowel adhesions; it can reduce the volume of primary tumor, and if the tumor location is close to the dentate line, it can make the surgery of preserving anal sphincter from impossible to possible, which improves the survival quality of patients; it can reduce pelvic lymph node staging, reduce the local recurrence rate of tumor, and improve the 5-year survival rate of patients, which is more important for patients with Dukes C stage more so.
2. Intraoperative radiotherapy: it can reduce local skin radiation damage and local recurrence. For certain more advanced cases, after surgical resection of the tumor lesion and lymph node dissection, intraoperative radiation therapy to the entire operative field at a higher dose is implemented, followed by suturing of the skin. This can kill the residual cancer cells at one time, prevent postoperative recurrence and prolong survival.
3.Postoperative radiotherapy: it can reduce local and regional recurrence and limit distant metastasis.
4.Simple radical radiotherapy: for certain aged and frail early-stage rectal cancer patients who are also suffering from cardiovascular disease or other visceral diseases and are not suitable for surgery, radical radiotherapy can be implemented.
5.Palliative radiotherapy: for certain rectal cancer patients who have lost the chance of radical surgery, radiation therapy can still be implemented to inhibit tumor development, control the disease and prolong life.
6.Treatment of metastatic cancer: radiation therapy is by far the best method to treat painful bone metastases. It can also play the role of inhibiting tumor growth and delaying life for brain metastasis.
2.Treatment by identification.
(1) Dampness and heat accumulation type; Bai Tou Weng Tang with reduction.
Bai Tou Weng 30g Qin Pi 15g Huang Lian 3g Huang Bai 9g Red Vine 15g Severus 15g Bitter Ginseng 15g Horsetail 15g White Hibiscus 12g Vine Pear Root 30g
(2) Internal obstruction by stasis and toxins: Diaphragmatic Stasis Removal Soup with Addition and Reduction.
Peach kernel 9g safflower 9g red peony 9g angelica 9g chuanxiong 6g wuling fat 9g aromatic herb 9g yuan hu 15g curcuma 15g ajwa 9g tu fu ling 30g
3) Spleen deficiency and qi stagnation type: Xiang Sha Liu Jun Zi Tang plus or minus.
Mu Xiang 6g sand 3g Radix Codonopsis 15g Atractylodes Macrocephala 12g Poria 12g Chen Pi 6g August Zha 12g Citrus aurantium 9g Wu Yao 9g Green Calyx Plum 9g Shen Xiang Qu 9g
4) Spleen and kidney Yang deficiency type:Lizhong Tang plus or minus.
Radix Codonopsis pilosulae 15g fried Atractylodes macrocephala 12g ginger charcoal 3g nutmeg 9g bone marrow 12g schisandrae 6g Cornu Cervi Pantotrichum 3g Radix et Rhizoma Polygoni 6g cinnamon 3g
(E) Local freezing, laser and cautery treatment for tumor. Patients with advanced rectal cancer accompanied by signs of incomplete intestinal obstruction can be treated with local freezing or cautery (including electrocautery and chemical cautery) to shrink or detach tumor tissues and temporarily relieve obstructive symptoms. In recent years, laser treatment is carried out, applying nd-yag laser with power 65w to irradiate local tumor tissues in points, and in case of bleeding, using power 40w to gather around the bleeding point to stop bleeding, and repeating irradiation every 2-3 weeks, the tumor of individual cases can be shrunk and temporarily relieve symptoms, which can be used as a palliative treatment method.
(F) Treatment of metastatic and recurrent patients. Surgery can certainly remove the cancer, but there are still residual cancer, or regional lymph node metastasis, or the presence of cancer thrombus in blood vessels, etc. The chance of recurrence and metastasis is very high.
1.Treatment of local recurrence. If the scope of local recurrence is limited and there is no recurrence or metastasis in other parts, it can be surgically explored and resected. If the recurrent foci are confined to the center of the perineal incision and the sides have not yet extended to the sciatic nodes, there is a possibility of extensive resection. If the perineal nodes or masses are pelvic recurrent foci extending to the lower pole of the perineum, surgery is not recommended because the foci cannot be completely removed, but the tumor tissues will be cut open, leaving a long lasting wound.
The recurrent lesion in pelvis is treated with radiation therapy, 20gy (2000rd) per course, which can temporarily relieve the pain symptoms.
2.Treatment of cancer metastasis. In recent years, many studies have confirmed that the effect of surgical resection of rectal cancer metastases is not as pessimistic as originally imagined. If liver metastases can be removed at the same time as the primary lesion, the survival rate can be improved. For a single metastasis, liver segment or wedge resection is feasible. In case of multiple liver metastases that cannot be surgically resected, decortication measures are first used, i.e. ligation of the hepatic artery to necrosis the hepatoma, followed by insertion of a catheter through the distal end of the ligated hepatic artery, from which fluorouracil and mitomycin are injected; hepatic artery embolization can also be used to significantly reduce the size of the tumor. However, the above treatment is contraindicated in patients with significant jaundice, severe liver function abnormalities, portal vein infarction, and those over 65 years of age. Radiotherapy can improve the symptoms of some patients.
(vii) Radiotherapy can effectively reduce the local recurrence of tumor.
Pre-operative and post-operative radiotherapy are both feasible. Pre-operative radiotherapy can improve the efficacy of surgery and reduce the recurrence rate of patients after surgery; post-operative radiotherapy can kill the residual microscopic lesions. It is also suitable for patients with advanced stage or postoperative recurrence.
(H) Immunotherapy is still inconclusive.
(ix) Gene therapy (Genetherapy) for rectal cancer is still relatively distant.
Common complications of rectal cancer.
1.Intestinal obstruction can cause narrowing of intestinal lumen and obstruction of intestinal contents, resulting in mechanical intestinal obstruction.
2.Intestinal perforation has typical clinical manifestations of acute abdomen, abdominal muscle tension, pressure pain and rebound pain, and X-ray plain film shows crescentic free gas under the septum, etc., which can make preliminary diagnosis.
3. Acute haemorrhage is a rare complication of colorectal cancer.
Characteristics of constipation caused by rectal cancer.
Rectal cancer, accounting for about 70% to 75% of the incidence of colorectal cancer. Constipation is often an early symptom of rectal cancer. As the cancer tissue forms a mass in the rectum which can cause rectal stenosis, or the lesion invades the rectal mucosa, causing impaired defecation reflex, making fecal discharge obstructed and constipation occurs. Its characteristics are.
(1) Blood in the stool. Constipation is often accompanied by blood on the surface of the stool, mostly fresh blood, in small amounts.
(2) Rectal irritation symptoms. Sometimes constipated patients also have symptoms of rectal irritation such as frequent stools, low volume, frequent bowel movements, incomplete defecation and anal drop.
(3) Stool deformation. Constipation sometimes see stool thinning or stool bar side of the groove, at this time to pay attention to the possibility of occupying lesions in the rectum.
(4) Systemic symptoms. In the late stage of rectal cancer, the symptoms of constipation are very prominent, the volume of stool is small, with blood, often squatting in the toilet for several minutes, but not easy to discharge stool. It is often accompanied by systemic symptoms such as anemia, malnutrition, weight loss and cachexia.
(5) Examination. Rectal diagnosis is the cheapest and most effective method for early detection of rectal cancer, while proctoscopy and sigmoidoscopy can directly extract tissues from the lesion for pathological examination.
Due to the high incidence of rectal cancer, it should be highly valued by constipated patients, especially elderly constipated patients, for early detection and early treatment.
Common complications of radiotherapy.
Complications of radiotherapy include local injury and systemic injury. Local injuries include radioactive dermatitis, radioactive enteritis, radioactive osteitis, etc.; systemic injuries include digestive system reaction and bone marrow suppression.
1) Local injury.
①radioactive dermatitis: at the early stage of radiation, the skin can be seen to be red and itchy, similar to sunburn dermatitis changes; in the middle of radiation, the skin pigmentation becomes thick and rough, and the pores are thick and black; in the late stage of radiation, wet peeling can occur in the skin folds and groin area, local skin swelling, and in severe cases, blisters, followed by rupture, erosion, and even ulcers.
②Radiation enteritis: In the middle and late stages of radiation, patients can feel abdominal discomfort, which is aggravated after eating or drinking, and intestinal obstruction can occur in severe cases. This is due to mucosal congestion and edema of the intestine under radiation damage.
③ soft tissue fibrosis: it appears in the late stage of radiation, often manifesting as local tissue hardening and loss of the elasticity of normal tissue.
2) Systemic adverse reactions.
①Gastrointestinal reactions: patients often have dry mouth and dry stools at the early stage of radiotherapy; in the middle and late stages of radiotherapy, patients may suffer from loss of appetite, nausea and vomiting.
② Myelosuppression: it mostly occurs in the late stage of radiotherapy, manifested as general weakness, and the total number of white blood cells (WBC) is found to decrease in hematological examination.
Recipes after radiotherapy.
Bird’s nest fig stew with rabbit meat Ingredients.
150g of rabbit meat, 10g of dried bird’s nest, 80g of figs Method.
1. Soak the dried bird’s nest in room temperature water for 6-8 hours, the ratio of bird’s nest to soaking water is 1:30-1:50.
2.Tear the soaked bird’s nest into strips, put them into a pot together with the soaking water, cook until the water boils and turn to low heat for 3-5 minutes, drain the bird’s nest for use, do not pour out the water for use.
3.Wash and slice the figs.
4, wash and cut the rabbit into small pieces.
5, figs and rabbit meat together into the stew pot, add boiling water (including the water to be used after the bird’s nest drained), stew pot with a lid, stew for 2 hours in water.
6, put the drained cooked bird’s nest, seasoning can be served. Effect: It is suitable for those who are weak, short of breath and dry mouth after radiotherapy.
Bird’s nest and snow fungus honey ingredients.
10g of dried bird’s nest, 15g of snow fungus, 15-24g of honey.
1.Soak the dried bird’s nest in room temperature water for 6-8 hours, the ratio of bird’s nest to soaking water is 1:30~1:50.
2. Soak the snow fungus in room temperature water and put it into a pot, add the right amount of water and boil it for a long time until it dissolves.
3.Tear the soaked and swollen bird’s nest into strips, put them into the pot together with the soaking water, cook until the water boils and turn to low heat for 3-5 minutes.
4, mix in 15-24 grams of honey and serve warm. Efficacy: It is suitable for those who have yin deficiency and blood heat, dry mouth and thirst after radiotherapy.
Three major principles of dietary therapy for rectal cancer
First, emphasize balanced nutrition and focus on supporting and supplementing deficiency. Internal deficiency” of rectal cancer patients is the main contradiction in the process of disease occurrence and development. It causes cancer because of deficiency, and causes deficiency because of cancer, and deficiency in the middle of reality, with deficiency as the basis. The purpose of food therapy is to ensure that rectal cancer patients have sufficient nutrition, improve the body’s ability to resist disease, and promote the recovery of patients. Therefore, the Nei Jing says: “The grain, meat, fruit and vegetables, food and nourishment are exhausted, without making too much of it, which hurts its positive.” Under the guidance of the general principle of supporting the righteousness and replenishing the deficiency, the food therapy for rectal cancer patients should be nutritious, diversified and balanced. As the Neijing says, “Five grains are nourishing, five fruits are helpful, five animals are beneficial, and five dishes are sufficient.” The loss of bias, it is harmful.
Second, familiar with the nature and taste of the attribution, emphasizing the identification of food
Rectal cancer is the same as other diseases, patients have different yin and yang, cold and heat, deficiency and reality. Food is also different from hot, cold, warm and cool, pungent, sweet, bitter, sour and salty. The five tastes of food should be cold and cold, while cold evidence should be warm and hot. Pungent taste is warm and dispersing, such as ginger and onion; sweet taste is moderate, such as yam, gorgonzola and syrup; light taste is percolating, such as winter melon and coix seed; sour taste is astringent, such as umeboshi and hawthorn; salty taste is soft and firm, such as seaweed, kombu and oyster.
Choose anti-cancer foods, and strive to be targeted
Food and medicine have the same origin, and some foods have both therapeutic and anti-cancer effects, so they can be selected and applied in a targeted manner. Foods beneficial to digestive tumors include leek, Ulva, cabbage, Chinese cabbage, lily, cuttle beans, etc. Foods in daily life such as garlic, soybean products, green tea, etc. are also good anti-cancer medicines.