Flashcards in COLON Deck (39):
The criteria for patients with acute uncomplicated diverticulitis to be treated in the outpatient setting include :
●Reliability to return for medical reevaluation if condition worsens
●Compliance with outpatient treatment plan
●Abdominal pain is not severe
●No higher than a low-grade fever
●Can tolerate oral intake
●No or minimal comorbid illnesses
●Available support system
Generally, the elderly, immunosuppressed, patients with significant comorbidities, and patients with high fever (>102.5°F/39°C) or significant leukocytosis should be hospitalized .
abx for divertic
quinolone with metronidazole,
amoxicillin-clavulanate - Augmentin
with metronidazole [12,13].
Our usual outpatient antibiotic regimen includes:
●Ciprofloxacin (500 mg PO twice daily) plus metronidazole (500 mg PO three times daily). Amoxicillin-clavulanate (875/125 mg twice daily) is an acceptable alternative. Oral ciprofloxacin achieves levels similar to those with intravenous administration, has broad coverage of enteric Gram-negative pathogens, and (similar to amoxicillin-clavulanate) requires only twice daily dosing, thus improving compliance.
For patients intolerant to metronidazole, clindamycin may be an acceptable alternative. For patients intolerant to metronidazole as well as beta lactam agents, moxifloxacin has reasonable gram-negative and anaerobic coverage.
Patients with acute COMPLICATED diverticulitis s
ampicillin-sulbactam (3 g every six hours) Unasyn
piperacillin-tazobactam (3.375 g IV every six hours) Zosyn
ticarcillin-clavulanate (3.1 g every six hours)
Indications for operative management for acute diverticulitis
Complications of diverticulitis
Abscess (failed percutaneous drainage)
Clinical deterioration or failure to improve with medical therapy
Inability to exclude carcinoma
? Young patient
o Stage 1: small or confined pericolic mesenteric abscess
o Stage 2: LARGE abscess in PELVIS (even if away from sigmoid perf site!
o Stage 3: perforated diverticulitis causing generalized purulent peritonitis
o Stage 4: rupture of diverticulum into peritoneal cavity with fecal contamination
bacteria being treated for early divertic dz
The patient has had 3 episodes of diverticulitis requiring hospitalization. All of
the episodes have responded to non-operative management.
recurrent diverticulitis is an indication for elective resection
Treatment: wait 6 weeks after acute episode; one stage surgery;
resection and primarynanastomosis;
entire sigmoid should be resected
distal extent of resection should be to the rectum (where teniae become confluent)
The patient was also noted to have fecaluria during her laboratory exam.
he diagnosis is confirmed by abdominopelvic computed tomography (CT) scan with oral or rectal but not intravenous (IV) contrast demonstrating air or contrast material in the bladder with adjacent thickened colonic and vesicular walls.
CT scan usually diagnostic
undergo colonoscopy to rule out an underlying malignancy (once cooled down)
Cystoscopy for suspected malignant fistula — When patients are suspected of having a malignant CVF, a cystoscopy should be performed to rule out bladder involvement.
managed non-operatively initially since many
fistulas will close spontaneously with resolution of the diverticulitis.
If the fistula persists and requires elective surgical treatment, the adherent sigmoid colon should be
removed and resected.
The bladder should be repaired and drained with a Foley. Anda primary colorectal anastomosis can usually be performed.
The addition of bowel rest and total parenteral nutrition is optional  but generally not required in the treatment of CVF.
surgical treatment of colovesical fistula
urinary catheter inserted and positioned so that it can be accessed during the operation.
mobilize the colon proximally and distally to the fistula.
Special attention must be paid to locate and preserve the left ureter.
In treating nonmalignant CVFs, the colon can often be dissected off the bladder using blunt dissection (the "pinch" technique).
avoid injuring the ureter.
Once separated, the fistulous tract itself may not be convincingly seen on either the bladder or the colon.
If necessary, the fistula may be located by distending the bladder with methylene blue solution instilled through the urinary catheter.
The bladder side of the fistulous tract can be managed by simple closure with absorbable sutures.
Partial cystectomy is not generally necessary since inflammation of the bladder is secondary to pathology in the colon and induration should resolve after the bowel has been resected.
Where possible, we place the omentum between the colon and the bladder .
In patients with complex inflammatory bowel disease, small bowel and other structures may be involved in fistula formation, which may necessitate resection of multiple loops of bowel. (See "Operative management of Crohn disease of the small bowel and colon".)
We prefer to leave the urinary catheter in for seven days in most patients after a CVF repair. A postoperative cystogram at the time of Foley catheter removal is generally unnecessary in simple cases but can be performed at the surgeon's discretion.
Crohn’s patients with fistula-in-ano
respond well to Infliximab
Work went Ogilvy's is suspected
Consider Gastrografin enema to rule out distal obstruction
Consider mu receptor antagonist medication
Cardiac monitor with neostigmine
what T stage would you start
Fu L OX left interior Samoans euros and Rose and some women are not present for disc disease
Low Anterior Resection
AND TME TECHNIQUE:
bleeding, anastamotic leak, erectile dysfuction
bowel prep, preop antibiotics, ureteric stents as needed
Support under the sacrum if APR
or coloanal anastomosis in to be done. Foley catheter. Prepped and draped in usual fashion
left colon line of Toldt. Identify the left ureter.
sigmoid mesentery on the RIGHT side is incised, extended distally to the right side of the rectum.
extend this disection superiorly to expose the origin of the inferior mesenteric artery.
divide and ligate just to the origin of the left colic artery (so desceding has blood supply)
inferior mesenteric artery is ligated with 0-0 silk sutures.
peritonealsigmoid mesocolon is scored with electrocautery, and the mesenteric vessels are divided and ligated.
distal descending colon is divided with a GIA stapling device (this will be prox anast)
superior hemorrhoidal vessels divided and ligated.
presacral space is entered at the sacral promontory.
peritoneum on each side of the rectum is divided just medial to the ureters and extended to meet anteriorly to gain access to the seminal vesicles in males or the rectovaginal septum in females.
posterior pelvic dissection is performed SHARPLY with electrocautery to remove the mesorectum intact with its fascial envelope.
retracting the rectum anteriorly with a malleable retractor.
The loose areolar tissue between the mesorectum and presacral fascia is divided.
peritoneal lining anteriorly is incised, and the bladder is retracted superiorly with a St. Mark’s deep pelvic retractor to open the plane.
Denonvilliers’ fascia is incised, and the anterior rectal wall is separated from the seminal vesicles and the posterior capsule of the prostate.
lateral stalks containing the middle hemorrhoidal vessels are clearly identified. keeping the ureters under view, secured with large hemoclips and divided.
rectum should rise out of the pelvis and a distal margin of 2-5 cm is marked.
rectum is divided using a TA 55 reticulating stapler.
A right angled or curved clamp is applied proximal to the staple line and the rectum is transected with a scalpel.
purse-string suture using 3-0 monofilament nonabsorbable suture is placed around the opening of the descending colon.
anvil of the EEA stapler is inserted into the descending colon and the purse-string suture is tied down.
end-to-end stapler, usually (29) 28 to 31 Fr, is lubricated well and inserted through the anal canal.
3. The spike of the stapler is advanced just anterior to the distal staple line and engaged to the anvil that is placed within the proximal bowel. The stapler is closed and fired.
integrity of the two tissue doughnuts is confirmed by inspection.
• The anastomosis is inspected with a flexible sigmoidoscope
. With the pelvis full with warm saline, air is instilled into the bowel with a sigmoidoscope
5. Hemostasis is obtained.
6. For an ultra-low colorectal anastomosis or coloanal anastomosis, a temporary diverting loop ileostomy should be considered.
The key technical points in TME include:
→initial entry into the retrorectal space
→identification of the hypogastric nerves and the pelvic autonomic nerve plexus
→ separation of the posterior visceral compartment from the anterior visceral compartment
→ the “lateral ligments” and the pelvic splanchnic or sacral parasympathetic nerves
→mobilization of the distal rectum in relation to the levator ani
→in the case of APR, perineal dissection
CONCENT: as for colectomy+
• . permanent colostomy
• . urethral injury
• . prolonged drainage and delayed closure of pereineal wound
• . impotence
Pre op Prep
o . Anal canal closed with heavy purse-string suture
o . just outside intersphincteric groove
- elliptical of midpoint extended laterally to include the intire sphincter mechanism
- . deepened into ischiorectal fossa to levator ani, just ext. to ext. sph
- . Inferior hemorrhoidal vessels and nerves controlled
expose anococcygeal lig posterioryly and incise it ant to coccyx
sharply divide ext sphincter and levator
leaving adequate cuff to close pelvic floor
pull rectum through perineal wound for traction
divide remaining external sphoincter and puborectalis
closure of perineum in layers
levator muscles approx. in midline with interrupted absorb sutur
fibrofatty tissue of ischeorectal fossa approximated
SC suture placed
skin closed with non-absorbable widely separated matres sutures
treatment of J pouch pouchtitis
IV Abx - flagyl
J Pouch, ileal and Colonic
small bowel mesentery is completely mobilized from the retroperitoneum up to the inferior border of the pancreas;
crucial for ensuring that there is adequate small bowel length to allow the ileal pouch to reach the pelvic floor.
visceral peritoneum should be scored along the right side of the superior mesenteric vessel.
it should be possible to pull the apex of the pouch 3 to 5 cm below the upper aspect of the pubic symphysis.
If, after full mesenteric mobilization and scoring of the visceral peritoneum, the pouch does not easily reach the pelvic floor, it may be necessary to divide either the ileocolic vessel or one of the proximal branches of the superior mesenteric vessels.
J-shaped reservoir (J pouch) constructed from the last 30 to 35 cm of the terminal ileum.
The ultimate reservoir capacity of the pouch should be approximately 400 ml.
Construction is begun by folding the terminal ileum into a J shape.
The hook of the J should be approximately 15 cm long. This efferent limb of the J is loosely secured to the afferent limb of the small bowel.
The reservoir is then formed by firing a 75 mm linear cutting stapler twice from the apex of the pouch, thereby dividing the common wall between the two limbs of the pouch.
loop ileostomy is constructed in the right lower abdomen.
Handsewn, rectal mucosectomy:
The second option is to perform a mucosectomy (other than J pouch)
of the anal canal and the lower rectal remnant. The dentate line area is exposed with the help of a self-retaining retractor. A dilute solution of epinephrine is injected into the submucosa to facilitate circumferential excision of the anal canal mucosa; the muscularis propria is left intact. The excision is extended proximally to the level of the stapled rectum. A side-to-end handsewn anastomosis between the apex of the pouch and the dentate line is performed with absorbable interrupted sutures. Once the anastomosis is completed, one or two closed suction drains are placed behind the pouch and brought out of separate left abdominal stab wounds. In the majority of patients, a loop ileostomy is constructed in the right lower abdomen
Retract the cecum toward midline
dissect alone the right peritoneal reflection, in the right colic gutter,
mobilizing the cecum and ascending colon to the hepatic flexure.
Care is taken to preserve/protect the duodenum and right ureter.
Divide right gastrocolic ligament to mid transverse colon
high ligation of iliocolic
ligate right colic
Divide the RIGHT branch of the middle colic supplying the hepatic flexure
Divide the bowel using firings of the 75’GIA stapler
Babcocks on antimesenteric ends of both ileal and transverse colon stumps,
excise antimesenteric corner,
insert 75 GIA and perform side-to-side (functional end-to-end) anastomosis.
Oversew staple line.
CLOSE MESENTERIC DEFECT!
Left hemi colectomy
IS THIS SPECIMIN INKED!
explore abdomen and identify lesion in left colon
Retract sigmoid/left colon toward midline
divide along line of toldt, carrying dissection to splenic flexure
gastrocolic ligament if omentum is to be removed
Otherwise, carefully detach omental attachments from left colon
small defect in the pericolonic mesentery and fire a 75 GIA stapler across distal margin.
If doing a low anterior resection, be sure to identify and include superior gluteal in mesenteric resection.
Identify origin of IMA and perform high ligation (taking the whole thing)
Divide mesentery between clamps, including the left branch of the middle colic artery.
Divide the proximal margin at the mid transverse colon.
Perform side to side (functional End to end) with 75 GIA
oversew staple line
Combo of right and left hemicolectomy
Start with right side and proceed distally
Consider +/- omentectomy
medications for UC
Associated findings with UC including extra intest
WILL NOT IMPROVE AFTER COLECTOMY:
primary sclerosing cholangitis
ocular manifestations - iritis,
Anterior uveitis or Iritis
Primary sclerosing cholangiti
Ileoanal reservoir inflammation
rule out undiagnosed Crohn's
Treatment with metronidazole and ciprofloxacin
May require ongoing suppressive antibiotic
Salicylate stool enema
Rarely pouch excision-not done urgently
Name common diarrhea infections
Management of radiation proctitis
sucralfate Senema first choice
If refractory then do workup:
Cystoscopy do without fistula
Biopsy to rule out malignancy
Formalin therapy (high success but can cause structure)
Argon or infrared coagulation
If this all fails:
During colostomy in continue medical therapy
Maybe a candidate for colon J pouch in anal anastomosis
If bleeding emergency may require APR
Bright red rectal bleeding typically comes from
colon or the rectum,
though in 10% to 15% of patients, brisk hematochezia results from upper gastrointestinal bleeding (UGIB),
(REMEMBER "UPPER GI" is proximal to Ligament of tritz - so entire small bowel other than duodeunm!)
another 10% to 15% originate in the small bowel.
most commonly identified source of major lower gastrointestinal bleeding (LGIB) in adults.
Other common causes include:
inflammatory bowel disease
n older adults
In children and young adults, LGIB is most commonly caused by
inflammatory bowel disease,
Minor intermittent bleeding in any age group may be related to
should be considered in patients with atherosclerotic disease, dehydration, or other causes of restricted mesenteric perfusion.
Work up and manage of bright red blood per rectum
hematocrit is 18%, and his coagulation studies are normal.
(aspirate is bilious, without blood)
(reveals small, nonbleeding hemorrhoids)
intensive care unit,
transfused with packed red blood cells.
if patient stable
treatement of repeat major bleed in patient with diverticulosis
Diverticular bleeding accounts for about half of acute LGIB hospitalizations in the United States, and an even greater share of cases among the elderly. Risk factors for bleeding among individuals with diverticulosis include systemic anticoagulation, hypertension, and use of nonsteroidal anti-inflammatory drugs or steroids. The bleeding can be massive and even life threatening, but it is often a diagnosis of exclusion, as the bleeding will cease spontaneously in 80% of cases, usually before the source can be identified. Recurrent bleeding will, however, occur in 15% to 30% of these patients. Initial management is supportive, including close hemodynamic monitoring and, in appropriate cases, blood transfusion. Surgery is rarely required for management, except in cases with hemodynamic instability refractory to resuscitation and transfusion, or
change that polyp is malignant
Approach to the Malignant Polyp
polyps greater than 2 cm have an approximately 30% risk of cancer.
tattooed at the site of any large polyp or any suspicious polyp in the event that further treatment and evaluation are necessary.
A malignant polyp is defined as
invades into, but no deeper than:
(this makes the lesion a T1 colon cancer)
what polyp finding that include adenocarcinoma in which you were done with negative margin polypectomy
polyp containing carcinoma
these are confined to the mucosa and lamina propria.
These entities have no metastatic potential and are cured with complete polypectomy.
The main reason to proceed with formal segmental resection when a malignant polyp has been removed with negative margins
harvest the associated mesenteric lymph nodes.
The risk of lymph node metastasis in malignant polyps ranges from 8% to 15%.
Traditionally, the Haggitt level
WAS used to classify malignant polyps and to predict lymph node metastasis (Box 1); however, the risk of lymph node metastasis in Haggitt level 4 lesions varies based on the depth of submucosal invasion.
Because of this, the submucosal invasion classification is being increasingly used.
The depth of "submucosal" (SM) invasion is stratified into three levels:
Sm1 (upper third of submucosa),
Sm 2 (middle third),
Sm3 (lower third).
Haggit levels 1 to 3 correspond with Sm1,
Haggit level 4 can be Sm1, Sm2, or Sm3!
indication for oncologic bowel resection with polyp
A malignant polyp with a Sm3 classification
high tumor grade,
extensive tumor budding,
if a malignant polyp has one of these features, that risk increases to 20%.
If two or more of these adverse features are present, the risk of adverse outcomes rises to 36%.
Other indications for oncologic bowel resection with polyp:
Pedunculated Haggitt level 4 with invasion into distal third of submucosa,
pedunculated lesions with lymphovascular invasion
Lesions removed with margin
Criteria for close surveillance after endoscopic removal of a malignant polyp include:
a microscopic margin of GREATER than 2 mm,
no lymphatic or vascular invasion,
moderate to well differentiation,
Haggit level 1 to 3,
Sm level 1 to 2.