A 65yr old male patient presents with history of early morning bloody diarrhoea, Change in bowel habits, Intermittent Obstruction.Sometimes he had a feeling of incomplete evacuation and Tenesmus. There is no positive family history for any carcinoma.What will be the treatment of choice in this case:

CA rectum- MC site of large bowel malignancy- Usually seen in 5th - 6 decade- MC site of metastasis - Liver > lungs - Chemotherapy regimen- FOL FOX-IV* FOL - Folinic acid/ leucovorin* F- 5-FV (5-Flurouracil)* Ox- Oxaliplatin Clinical features- MC symptom - Bleeding PR- Early morning bloody diarrhea- Passage of bloody slime (no fecal matter) - Spurious diarrhea (every 2 to 3 hours, rectum is full with discharge from tumor, so patient passes like stool every 3 hours)- Tenesmus - Painful defecation with sensation of incomplete evacuation seen in lower pa of CA rectum- Back ache/ sciatica (sacral plexus involvement posteriorly)- Weight loss (liver metastasis) Investigations- Length of anal canal - 3cm- length of rectum - 14cm- For complete evaluation, the length of the instrument should be at least 17 cm Investigations Options available- PROCTOSCOPY- Sigmoidoscopy- Colonoscopy* Length of proctoscope - 10 cm* Rigid sigmoidoscope -25 cm* Flexible sigmoidoscope- 60cm* Colonoscope - 160 cm- Investigation of choice - Rigid sigmoidoscopy + biopsy- Colonoscopy is mandatory for adequate evaluation of whole colon and to rule out any synchronous polyp or synchronous malignancy* Synchronous- simultaneously* Metachronous- later after surgery- Viual colonoscopy (3D reconstruction colonoscopy using CT) * Advantage - can visualize outside of lumen also* Disadvantage - Biopsy of colon cannot be done- In head & neck malignancies & pelvic malignancies, overcrowding of nerves, blood vessels & soft tissues. So, IOC for staging of most of head and neck malignancy- MRI- For T- staging, investigation of choice- TRUS (Transrectal ultrasound)- Distantly lying nerve, lymph node, vessel cannot be differentiated as Sensitivity of ultrasound decrease if distance between probe & organ increase. - For lymph node staging, investigation of choice is - Endorectal MRI- Overall Best investigation for staging- MRI Treatment- Principle of treatment in CA Rectum* Stage I - Surgical resection* State II & III - Neoadjuvant chemoradiation followed by surgical resection (down stage the tumor & then surgery)* Stage IV - Neoadjuvant chemoradiation followed by palliation +- surgical excision - TOC- TOTAL MESORECTAL EXCISION* Given by Bill Heald* Significant length of bowel removal around the tumor* Removal of Surrounding tissues up to the plane between Mesorectum & Presacral Fascia known as HEALD'S HOLYPLANE - If CA rectum is located > 5 cm above Anal verge - Low Anterior Resection (LAR)- If CA rectum is located at or below 5 cm from anal verge - APR (Adomino Perineal resection) aka Mile's Procedure - In elderly patient >60 years with malignancy in sigmoid/ or proximal pa of rectum which is intraperitoneal - Haman's procedureHaman's procedure* Sigmoidectomy +Descending colostomy + Closure of rectal stump