Ppt Bedah Digestif

51
LAPORAN KASUS TUMOR RECTOSIGMOID Pandu satya widiarto Karmila karim Hafidhu Nalendra M. Dadan kurniawan Pembimbing : dr Taslim P SpB(K)BD

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CA RECTOSIGMOID CASE

Transcript of Ppt Bedah Digestif

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LAPORAN KASUSTUMOR RECTOSIGMOID Pandu satya widiarto

Karmila karim

Hafidhu Nalendra

M. Dadan kurniawan

Pembimbing : dr Taslim P SpB(K)BD

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LAPORAN KASUS• Identitas

Nama : Ny. DNo.RM : 01308918Jenis kelamin : PerempuanTanggal lahir : 23-06-1978 (36 thn)Agama : ISLAMPendidikan : Tamat SLTAPekerjaan : Ibu rumah tanggaTanggal masuk RS : 22-09-14

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ANAMNESIS

Diambil secara auto anamnesis pada hari selasa 4-November-2014, di gedung teratai RS Fatmawati.

KELUHAN UTAMA

• Mual dan muntah sejak 1 bulan SMRS

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ANAMNESIS

RIWAYAT PENYAKIT SEKARANG

Pasien perempuan datang ke IGD RS

Fatmawati dengan keluhan mual muntah sejak 1

Bulan SMRS, rasa mual pertama kali dirasa pada

saat sore hari ketika pasien sedang beraktifitas,

keluhan mual datang terus menerus dan pasien

muntah dengan isi cairan dan makanan, darah (-),

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ANAMNESIS• RIWAYAT PENYAKIT SEKARANG (2)

Setelah 2 minggu merasakan mual dan muntah

pasien mulai menyadari terdapat benjolan dibagian

perut kanan bawah berjumlah 1 yang berukuran sebesar

bola bekel, dan tidak terasa sakit, benjolan tersebut

semakin lama diakui oleh pasien semakin besar dan 1

minggu SMRS terasa sedikit sakit bila ditekan, dan

keluhan mual muntah semakin sering sekitar 4 kali

sehari.

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ANAMNESIS

• RIWAYAT PENYAKIT SEKARANG (3)

BAK pasien normal secara intensitas dan

tidak ada nyeri, pasien pernah mengeluh BAB

berdarah 1 kali dan bab rasa tidak puas, demam (-)

pasien merasakan penurunan berat badan namun

diakui napsu makan pasien tetap seperti biasanya.

Pasien juga mengeluh mudah lelah dan sering sakit

kepala.

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ANAMNESIS• RIWAYAT PENYAKIT DAHULU

Pasien tidak pernah mengalami keluhan mual dan muntah yang berkepanjangan, dan tidak pernah ada riwayat tumbuh benjolan.

- Hipertensi (+)- DM (-)- Asma (-)- Alergi (-)- Maag (-)

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ANAMNESIS• RIWAYAT PENYAKIT KELUARGA

Tidak ada keluarga pasien yang memiliki hal serupa.

- Hipertensi (+)- DM (-)- Asma (-)- Alergi (-)- Tumor (-)

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PEMERIKSAAN FISIK• Keadaan umum

Kesadaran : Compos mentisKesan sakit : Sakit ringan

• Status generalis

Kepala : NormocephaliMata : Ca -/- SI -/-Hidung : Deformitas (-), perdarahan

(-)Telinga : Normotia, sekret (-)Mulut : Oral hygiene baik,

Tonsil T1Leher : Tiroid TTM

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PEMERIKSAAN FISIKThorax

Cor : BJ I/II Reg, M (-), G (-)Pulmo : SNV +/+, Rh -/-, wh-/-

Status Lokalis :Abdomen

I : Perut datar, Efloresensi bermakna(-)A : Bu +Pa : Supel, NT -, defans (-), didapatkan

massa dengan konsistensi keras berbatas tegas sebesar telur ayam

P : TimpaniEkstermitas : Akral hangat, edema -/-, CRT <3”

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PEMERIKSAAN PENUNJANG• Laboratorium

PEMERIKSAAAN HASIL NILAI RUJUKAN

Hemoglobin 13,4 g/dl 11,7-15,5

Hematokrit 39% 33-45

Leukosit 6,8 ribu/ul 5-10 ribu

Trombosit 315 ribu/ul 150-440

Eritrosit 4,34 juta/ul 3.80-5,20

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PEMERIKSAAN PENUNJANGHASIL NILAI RUJUKAN

Natrium 144 mmol/l 27.4-39,3

Kalium 3,40 mmol/l 11.3-14.7

Klorida 106 mmol/l

FUNGSI GINJAL

UREUM 15 mg/dl 20-40

KREATININ 0,6 mg/dl 0,6-7,5

Albumin 5.00 3,40 - 4,80

GDS 80 mg/dl <140

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PEMERIKSAAN PENUNJANGCT-SCAN ABDOMEN

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PEMERIKSAAN PENUNJANG

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HASIL CT-SCAN ABDOMEN• Terdapat lesi isodens menyangat kontras rectosigmoid diameter +/- 4cm. Belum tampak infiltrasi

• Kesan : Massa rectosigmoid

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PEMERIKSAAN PENUNJANG

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DIAGNOSIS• Diagnosis kerja

Tumor rectosigmoid

Penegakkan diagnosis, anamnesis, pf, laboratorium, pencitraan.

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TATALAKSANA• OPERATIF

LAR rectosigmoid

• Konservatif

Medikamentosa :

- Corderin 1x16mg

- Amlodipin 1x50mg

- Ondansetron 1x80mg k/p

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LAPORAN OPERASI• Tanggal 5-11-14• Diagnosis sebelum operasi : Tumor rectosigmoid• Macam operasi : Laparatomy eksplorasi, eksisi massa• Jam mulai 12:30• Jenis Anestesi GA

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LAPORAN OPERASI• Pasien dalam posisi supine dalam pengaruh GA• Insisi mediana dari umbilicus s/d simfisis pubis lapis demi lapis.• Peritoneum dibuka tak terlihat massa• Evaluasi : Saluran cerna baik, tak ditemukan massa atau perlengketan

rahim membesar, teraba bagian yang keras di cervix-portio uterusKonsul intra op SpOG dr Hamim : Parut pasca SC, tak ada kelainan lain di genitalia interna yang memerlukan tindakan di bidang Obsgyn.

• Massa yang teraba klinis Dinding abdomen RUO• Eksisi massa dengan insisi transv diatas massa lapis demi lapis• Massa di eksisi PA• Luka dijahit lapis demi lapis dengan memasang 1 Polypropelene mesh

sublay technique. • Luka insisi mediana dijahit• Op selesai

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Instruksi post op• Awasi TNSP• Diet biasa• Ceftriaxone 1x2gr gr• Ketese 3 x 30 mg• Ozid 2 x 40mg• IVFD Rl : D5% 2:2

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PROGNOSIS• Ad vitam : Bonam• Ad sanationam : dubia ad bonam• Ad fungtionam : dubia ad bonam

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PEMBAHASAN KASUS

ANAMNESIS

Pasien perempuan datang ke IGD RS Fatmawati dengan keluhan mual muntah sejak 1 Bulan SMRS, terdapat benjolan pada perut kanan yang terasa sakit.

PEMERIKSAAN FISIK

Perut datar, Efloresensi bermakna(-) Bu + Supel, NT -, defans (-), didapatkan massa dengan konsistensi keras berbatas tegas sebesar telur ayaTimpani

PENUNJANG

CT SCAN

COLONOSCOPY

TUMOR

RECTOSIGMOID

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TINJAUAN PUSTAKA

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• Rectum memiliki 3 buah

valvula : superior kiri, medial

kanan dan inferior kiri.

• 2/3 bagian distal rectum

terletak di rongga pelvic dan

terfiksir, sedangkan 1/3

bagian proksimal terletak

dirongga abdomen dan relatif

mobile. Kedua bagian ini

dipisahkan oleh peritoneum

reflectum dimana bagian

anterior lebih panjang

dibanding bagian posterior.

REKTUM

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• Superior 1/3rd of the rectum

• Covered by peritoneum on the anterior and lateral surfaces

• Middle 1/3rd of the rectum• Covered by peritoneum on the

anterior surface• Inferior 1/3rd of the rectum

• Devoid of peritoneum• Close proximity to adjacent

structure including boney pelvis.

Peritoneal Relations

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Arterial supply• Superior rectal A – fr. IMA; supplies

upper and middle rectum• Middle rectal A- fr. Internal iliac A.

(supplies lower rectum)• Inferior rectal A- fr. Internal pudendal

A.

Venous drainage• Superior rectal V- upper & middle third

rectum• Middle rectal V- lower rectum and

upper anal canal• Inferior rectal vein- lower anal canal

Innervations• Sympathetic: L1-L3, Hypogastric

nerve• ParaSympathetic: S2-S4

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Lymphatic drainage• Upper and middle rectum

• Pararectal lymph nodes, located directly on the muscle layer of the rectum

• Inferior mesenteric lymph nodes, via the nodes along the superior rectal vessels

• Lower rectum• Sacral group of lymph nodes

or Internal iliac lymph nodes

• Below the dentate line • Inguinal nodes and external

iliac chain

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Epidemiology

• Colorectal cancer is the third most frequently diagnosed cancer in the US men and women.

• 108,070 new cases of colon cancer and 40,740 new cases of rectal cancer in the US in 2008. Combined mortality for colorectal cancer 49,960 in 2008.

• Worldwide approx. 1 million new cases p.a. are diagnosed, with 529,000 deaths.

• Incidence rate in India is quite low about 2 to 8 per 100,000

** Globocan IARC 2008

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• Cecum 14 %

• Ascending colon 10 %• Transverse colon 12 %

• Descending colon 7 %

• Sigmoid colon 25 %

• Rectosigmoid junct 0.9 %

• Rectum 23 %

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Etiological agents Environmental & dietary factors Chemical carcinogenesis.

Associated risk factors Family history of colorectal cancer Personal history of colorectal cancer, ovary, endometrial,

breast Excessive BMI Excessive alcohol intake Low folate consumption Neoplastic polyps.

Hereditary Conditions

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Clinical Presentations

• Symptoms• Asymptomatic• Change in bowel habit (diarrhoea, constipation,

incomplete evacuation).• Abdominal discomfort (pain, fullness, cramps, bloating,

vomiting).• Weight loss, tiredness.

• Acute Presentations• Intestinal obstruction.• Perforation.• Massive bleeding.

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• Signs• Pallor• Abdominal mass• Jaundice• Nodular liver• Ascites

• Rectal metastasis travel along portal drainage to liver via superior rectal vein.

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Tis T1 T2 T3 T4

Extension to an adjacent organ

MucosaMuscularis mucosae

Submucosa

Muscularis propria

Subserosa

Serosa

TNM ClassificationTX Primary tumor cannot be assessedT0 No evidence of primary tumorTis Carcinoma in situ: intraepithelial or invasion of lamina propriaT1 Tumor invades submucosaT2 Tumor invades muscularis propria

T3 Tumor invades through the muscularis propria into pericolorectal tissues

T4a Tumor penetrates to the surface of the visceral peritoneum

T4b Tumor directly invades or is adherent to other organs or structures

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TNM Classification

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Prognostic factors

Good prognostic factors Gender(F>M) Asymptomatic Polypoidal lesions Diploid

Poor prognostic factors Obstruction Perforation Ulcerative lesion Adjacent structures

involvement Positive margins Signet cell carcinoma High CEA Tethered and fixed

cancer

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Stage and Prognosis

Stage 5-year Survival (%)

0,1 Tis,T1;No;Mo > 90I T2;No;Mo 80-85II T3-4;No;Mo 70-75

III T2;N1-3;Mo 70-75III T3;N1-3;Mo 50-65

III T4;N1-2;Mo 25-45IV M1 <3

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Diagnostic Workup

• History—including family history of colorectal cancer or polyps

• Physical examinations complete pelvic examination in women: size, location, ulceration, mobile, sphincter functions.

• Proctoscopy—including assessment of mobility, minimum diameter of the lumen, and distance from the anal verge

• Biopsy of the primary tumor

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CT scan

• Part of routine workup of patients• Useful in identifying enlarged pelvic lymph-nodes and metastasis outside the pelvis than the extent or stage of primary tumor

• Limited utility in small primary cancer• Sensitivity 50-80%• Specificity 30-80%• Ability to detect pelvic and para-aortic lymph nodes is higher than peri-rectal lymph nodes.

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Figure: Mucinous adenocarcinoma of the rectum. CT scan shows a large heterogeneous mass (M) with areas of cystic components. Note marked luminal narrowing of the rectum (arrow).

Figure:   Rectal cancer with uterine invasion. CT scan shows a large heterogeneous rectal mass (M) with compression and direct invasion into the posterior wall of the uterus (U).

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Magnetic Resonance Imaging (MRI)

• Greater accuracy in defining extent of rectal cancer extension and also location & stage of tumor

• Also helpful in lateral extension of disease, critical in predicting circumferential margin for surgical excision.

• Different approaches (body coils, endorectal MRI & phased array technique)

• Mercury study: • 711 patients from 11 European centers.• Extramural tumor depth by MR & histo-pathological

evaluation equivalent.

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Treatment

Surgery Chemotherapy Radiotherapy

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Surgery

• Surgery is the mainstay of treatment of • Local recurrence after conventional surgery:

• 20%-50% (average of 35%)**

• Radiotherapy significantly reduces the number of local recurrences

** Reference: facts taken from Perez

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Types of Surgery• Local excision- reserved for superficially invasive (T1)

• Should be considered a total biopsy, with further treatment based on pathology

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• Low Anterior Resection - for tumors in upper/mid rectum; allows preservation of anal sphincter

• Abdominoperineal resection• for tumors of distal rectum with distal edge up to 6 cm

from anal verge• associated with permanent colostomy and high incidence

of sexual and genitourinary dysfunction

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Total mesorectal excision• local failures are most often due to inadequate surgical

clearance of radial margins.

• local recurrence with conventional surgery averages approx. 25-30% vs. TME 4-7% by several groups (although several series have higher recurrence)

** referred from Perez

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Complications of Surgery

• Bleeding• Infection• Anastomotic Leakage• Blood clots• Anesthetic Risks

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Adjuvant therapy

ChemotherapyRadiation therapy

with or without chemotherapy

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Purpose of Radio(chemo)therapy in Rectal Cancer

• To lower local failure rates and improve survival in resectable cancers

• to allow surgery in primarly inoperable cancers

• to facilitate a sphincter-preserving procedure

• to cure patients without surgery: very small cancer or

very high surgical risk

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TERIMAKASIH

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“Jika tua nanti kita telah hidup masing-masing, ingatlah hari ini”