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Flashcards in COLON Deck (39):
1

The criteria for patients with acute uncomplicated diverticulitis to be treated in the outpatient setting include [7]:



●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 [2].

2

abx for divertic

gastrointestinal flora
Gram-negative rods
anaerobes,

particularly
E. coli
B. fragilis).

choices include
quinolone with metronidazole,
amoxicillin-clavulanate - Augmentin
trimethoprim-sulfamethoxazole Bactrim
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
OR
piperacillin-tazobactam (3.375 g IV every six hours) Zosyn
OR
ticarcillin-clavulanate (3.1 g every six hours)

3

Indications for operative management for acute diverticulitis

uptodate:


Absolute:
Complications of diverticulitis
Peritonitis
Abscess (failed percutaneous drainage)
Fistula
Obstruction
Clinical deterioration or failure to improve with medical therapy
Recurrent episodes
Intractable symptoms
Inability to exclude carcinoma

Relative
Symptomatic stricture
Immunosuppression
Right-sided diverticulitis
? Young patient

4

Hinche class


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

5

bacteria being treated for early divertic dz

"BECK"

Bacteroides,
clostridium,
E. coli,
Klebsiella

6

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)


7

The patient was also noted to have fecaluria during her laboratory exam.

colovesical fistula.

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 [2] but generally not required in the treatment of CVF.

8

surgical treatment of colovesical fistula

urinary catheter inserted and positioned so that it can be accessed during the operation.

uretral stents

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 [37].

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.

9

Crohn’s patients with fistula-in-ano

respond well to Infliximab

10

Work went Ogilvy's is suspected

Consider Gastrografin enema to rule out distal obstruction

Consider mu receptor antagonist medication

Cardiac monitor with neostigmine

Atropine available

11

what T stage would you start

T3

Fu L OX left interior Samoans euros and Rose and some women are not present for disc disease

12

Low Anterior Resection


AND TME TECHNIQUE:
Consent:
bleeding, anastamotic leak, erectile dysfuction
PREOPERATIVE PREPARATION:
bowel prep, preop antibiotics, ureteric stents as needed

PROCEDURE

lithotomy position.

Support under the sacrum if APR

or coloanal anastomosis in to be done. Foley catheter. Prepped and draped in usual fashion

vaginal irrigation.

packing SB.

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

REF: ZUIDEMA



13

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

. INCISION:
- 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

remove specimin


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

14

treatment of J pouch pouchtitis

FFA flush

IV Abx - flagyl

15

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.

To confirm
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.

16

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

17

Right HC

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

Score mesentery,

high ligation of iliocolic

ligate right colic

preserve SMA.

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!


18

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

IDENTIFY URETER

ligate
splenocolic ligament
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.

Score mesentery.

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

CLOSE MESENTARY

oversew staple line

19

Subtotal colectomy

Combo of right and left hemicolectomy

Start with right side and proceed distally

Consider +/- omentectomy

20

medications for UC

Steroids
Five ASA
Methotrexate
Six mercaptopurine

21

Associated findings with UC including extra intest

WILL NOT IMPROVE AFTER COLECTOMY:

ankylosing spondylitis
primary sclerosing cholangitis


ocular manifestations - iritis,
uveitis,

Dermatological
Erythema nodosum
Pyodema gangrenosum
Opthomologic
Anterior uveitis or Iritis
Episcleritis
Rheumatologic
Peripheral arthropathy
sacroiliitis
Ankylosing spondylitis
Vascular
Thromboembolic disease
Vasculitis
Hepatobiliary
Primary sclerosing cholangiti

22

pouchitis


Ileoanal reservoir inflammation
Needs endoscopy
Biopsy
Incidence 30-55%
rule out undiagnosed Crohn's
Treatment with metronidazole and ciprofloxacin

May require ongoing suppressive antibiotic

Salicylate stool enema
Probiotics

Rarely pouch excision-not done urgently

23

Name common diarrhea infections

c diff

Giardia

shigella
E. coli

Salmonella

Dysentery

24

Management of radiation proctitis

sucralfate Senema first choice

Steroid enema

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

25

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.

26

most commonly identified source of major lower gastrointestinal bleeding (LGIB) in adults.

Diverticular hemorrhage


Other common causes include:
inflammatory bowel disease
neoplasms,

n older adults

colonic angiodysplasia.

27

In children and young adults, LGIB is most commonly caused by

inflammatory bowel disease,

Meckel’s diverticula,

benign polyps.

28

Minor intermittent bleeding in any age group may be related to

anorectal disease:

hemorrhoids

fissures.

Ischemic colitis

should be considered in patients with atherosclerotic disease, dehydration, or other causes of restricted mesenteric perfusion.

29

Work up and manage of bright red blood per rectum

venous access,
crossmatch

hematocrit is 18%, and his coagulation studies are normal.

Nasogastric tube
(aspirate is bilious, without blood)

Anoscopy
(reveals small, nonbleeding hemorrhoids)

intensive care unit,
resuscitated
transfused with packed red blood cells.

bowel preparation
if patient stable

colonoscopy t

extensive diverticulosis

30

treatement of repeat major bleed in patient with diverticulosis

mesenteric angiography

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

31

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.

32

A malignant polyp is defined as

adenocarcinoma

invades into, but no deeper than:
submucosal
(this makes the lesion a T1 colon cancer)

33

what polyp finding that include adenocarcinoma in which you were done with negative margin polypectomy

polyp containing carcinoma

in situ
or
high-grade dysplasia,

these are confined to the mucosa and lamina propria.

These entities have no metastatic potential and are cured with complete polypectomy.

34



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%.



35

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.

36

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!

37

indication for oncologic bowel resection with polyp

A malignant polyp with a Sm3 classification

high tumor grade,

extensive tumor budding,

lymphovascular invasion

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,
or
pedunculated lesions with lymphovascular invasion


Lesions removed with margin

38

Criteria for close surveillance after endoscopic removal of a malignant polyp include:

complete excision,

a microscopic margin of GREATER than 2 mm,

no lymphatic or vascular invasion,

moderate to well differentiation,

Haggit level 1 to 3,

or

Sm level 1 to 2.

39

The Haggitt classification.

Histological classification of the extent of invasion of pedunculated malignant colorectal polyps.

Level 0:
Carcinoma in situ
or
intramucosal carcinoma.
Not invasive.

Level 1:
invading through muscularis mucosa into SUBMUCOSA, BUT limited to the HEAD of the polyp.

Level 2:
invading the level neck

Level 3:
invading the stalk.

Level 4:
invading the SUBMUCOSA of the bowel wall BELOW the STALK but above the muscularis propria.