Colon and Rectum Flashcards
(182 cards)
1
Q
Acute Right Lower Quadrant Pain ddx?
A
- DDx- Terminal ileitis (yersenia, typhlitis, CMV, TB, crohns, mesenteric lymphadenitis)
- Meckels diverticulitis
- Colitis (ischemic, bacterial, neutropenic, CMV, diverticulitis in a redundant sigmoid)
- tuba-ovarian path (should be dx by ultrasound or CT ex ectopic pregnancy, PID, turbo-ovarian abscess, ruptured ovarian cyst or twisted ovarian cyst)
- cecal cancer
- Carcinoid tumor in appendix
- Mucocele (ruptured or intact)
- remote sources (acute cholecystitis, diverticulitis, perforated PUD, ureteral colic and pyelonephritis)
2
Q
Acute Right Lower Quadrant Pain labs?
A
pregnancy test childbearing
3
Q
Acute Right Lower Quadrant Pain imaging?
A
- Imagine
- plain abdominal XRAY (fecalith, mass, localized ileus)
- Ultrasound of pelvis can be helpful
- CT PO and IV abx in borderline cases
4
Q
Acute Right Lower Quadrant Pain surgery?
A
dx laparoscopy
5
Q
Acute Right Lower Quadrant Pain treatment for Lymphoma, crohns, meckels, tubo ovarian, Ectopic, PID, Ruptured ovarian cyst, twisted ovarian, acute cholecystitis, diverticulits, periappendiceal?
A
- Treatment
- lymphoma- medical
- crohns in TI- appendectomy unless base is involved
- Meckels- wide mouth- limited segmental bowel resection with anastomosis
- incidental in adults- leave may be in children
- Tubo-ovarian- do appendectomy and get out unless some life threatening path that needs addressing may have to open
- Ectopic pregnancy- unruptured- salpingotomy +evac content+hemostasis and repair (keep ovary)
- ruptured- unilateral salpingectomy (keep ovary)
- PID- (swelling in tubes and hyperemia)
- Rocephin and Doxycycline
- if advanced and necrotic tubo-ovarian abscess with peritonitis
- unilateral salpingo-oophorectomy +lavage and drain
- Ruptured Ovarian Cyst
- Lavage (send to path) +cystectomy and repair ovary most are corpus lute cysts
- Twisted Ovarian cyst
- Do unilateral salpingo-oophorectomy only if ovary is infarcted
- Acute cholecystitis
- do both the appendectomy and cholecystectomy
- Diverticulitis
- do appendectomy and medical management for sigmoid tic
- Acute appendicitis with acutely inflamed cecum and necrotic appendiceal base
- perform partial cecum resection through healthy area in the cecum avoiding the necrotic portion using stapler avoid ileocecal valve
- Periappendiceal abscess
- well localized and minimal systemic sx
- perc CT guided drain c abx
- f/u in 2-3 mo elective appendectomy
- Looking sick, generalized peritonitis, or etiology is unclear
- surgical exploration, abs coverage, appendectomy and drainage , wound left partially open
- cont antibiotics until drain is removed and patient afebrile for more than 24hrs
- Patient is 2 mo s/p MI and frail
- conservative and consider percutaneous drain by CT or US, abs,
- follow up appendectomy 2-3 mo
- colonoscopy
- well localized and minimal systemic sx
6
Q
Acute Right Lower Quadrant Pain carcinoid tumor?
A
- Appendiceal Carcinoid Tumor
- 1/100 appys appendical cancers found
- preop if you know check plasma chromgranin A and if elevated get a octreotide scan, high risk patients need endoscopic evaluation, >2cm right hemi
- NETs 2cm, goblet cell adenocarcinoid tumor of any size, positive mesoappendix or vascular invasion, localized at the base of appendix, positive margins or evidence of nodal mets require Right Hemicolectomy can also consider for NETs 1-2cm with unfavorable histo
7
Q
Lower GI bleed ddx?
A
- DDX-UGIB 15%, diverticula, IBD, Neoplasms, angiodysplasa, kids IBD, meckels
- minor bleeding -anorectal
8
Q
Lower GI bleeding RF?
A
RF- anticoag, HTN, NSAIDS, steroids
9
Q
Lower GI bleeding ABC?
A
- ABCs-
- HD monitoring, IVF, type and cross, labs , EKG
10
Q
Lower GI bleeding tx?
A
- r/o UGI,
- NGT need bile return possible EGD
- Anoscope
- Stabilize with blood products, foley etc
- Bowel prep and colonoscopy (if stable) tattoo clip cautery, epinephrine, cauterization, can be performed promptly or wait studies don’t show on better than the other (however all should get one to r/o neoplasm
- Angio and embolization (brisk bleeding) (SMA and IMA 1st and if both are negative then celiac)
- can have tx value with vasopressin infusion or embolization
- can convert an emergent operation in an unstable patient to an elective one-stage procedure
- If negative then slow enough for
- tagged RBC scan,
- Followed by colonscopy r/o ischema (20%) so colon resection not mandatory
- If angio doesn’t stop bleeding but bleeding is localized than they can leave the catheter in bleeding vessel to localize during surgery
- right side- primary resection
- left side- MF/colostomy
- if not localized then Segmental resection in absence of a source is discouraged just to a total abdominal colectomy primary ileo-rectal anastomosis
11
Q
Lower GIB after all eforts to try and localize?
A
- Total abdominal colectomy (cancer vs noncancer?)
- after all efforts to try and localize
- coags foley cvl possibly a line
- lithotomy
- notable colonoscopy c CO2, colonoscope passed orally can evaluate the entire small bowel manually reducing bowel over scope
- bimanual palpation
- colonoscope make sure no blood proximal to the cecal valve
- TAC
- mobilize ascending colon and hepatic flexure ligate ileocolic vascular pedicle and divide ileum
- separate transverse colon from omentum preserving gastroepiploics
- mobilize sigmoid and descending colon take down splenic flexure and ligate inferior mesenteric and middle colic vascular pedicle
- mobilize and ligate upper mesorectum and divide across upper rectum
- ileorectal anastomosis (usually not a good idea patient is unstable, comorbidities, or poor anal function, fecal incontinece) vs ileostomy (mucous fistula if it can reach mostly won’t)
- routine dvt px
- loose stool may need loperamide to avoid dehydration
12
Q
Lower GIB note?
A
- In cases of diverticulitis most bleeds stop spontaneously, a second rebelled is considered by most surgeons indication for surgery
- Uncontrolled massive rectal bleeding rectal cancer then APR (high incident of rectal ischemia if embolize)
13
Q
Colonic polyps types?
A
- Types
- Hyperplastic - small, usually
14
Q
Colonic polyps treatment ? insitu? Polyps invading MM? polps stalk invading with cancer? sessile ? 7 cm anal verge? FAP greater than 10 polyps?
A
- Treatment for Neoplastic Polyp
- greater than 2 cm have 35% chance of cancer and 50% villous
- In-situ-
- polypectomy is enough
- follow up with colonoscopy
- Polyp c cancer invading muscularis mucosa (not propria)
- Polypectomy good enough and freq f/u if….
- if clear margins 2mm
- well differentiated
- no angio or lymphatic invasion
- no evidence of LN enlargement
- If not met then needs cancer operation
- Polypectomy good enough and freq f/u if….
- Polyp stalk is invaded with cancer
- cancer operation
- Polyp is sessile can’t be removed safely by colonoscopy
- 7cm above the anal verge
- segmental colon resection
- 7cm below the anal verge
- transrectal local resection (even if cancer insitu) o/w APR
- 7cm above the anal verge
- FAP >10 polyps
- AD, 100% malignant potential
- Px total colectomy at age 20
- check duodenum
- Tx
- Proctocolectomy, rectal mucosectomy, ileoanal pouch (J-Pouch)
- lifetime surveillance for residual rectal mucosa
15
Q
HNPCC traits?
A
- AD
- Right sided
- ovarian and endometrial or bladder cancer
- surveillance colonoscopy starting 25 yrs and endometrial biopsy q3yrs
16
Q
HNPCC tx?
A
- tx
- subtotal colectomy c first cancer operation
- Proctocolectomy + rectal mucosectomy + pull through oleo-anal anastomosis (procedure of choice)
- risks - retrograde ejaculation, soilage (should improve over 12 months)
- Total abdominal colectomy
- close to bowel wall (avoid ejaculatory problems)
- rectal dissection is continued a distance of 5 cm from the dentate line
- rectum is transected with GA stapler
- Ileum is mobilized as much as possible (incise mesentery away from marginal arteries all the way to root of mesentery)
- rectal mucosectomy
- dilate anus by exertion the rectal stump
- diluted epi in submucosa and carrying out the mucosectomy c Bovie from the dentate line upward leaving 5 cm mucosal cuff
- J-pouch
- folding 18cm of distal ileum on itself
- making a 3cm enterotomy at the J apex and introducing a long GIA through rectal muscular cuff to the anus
- 3-0 vicryl interrupted to anastomose the enterotomy at the apex of the J pouch to the anus at the dentate line
- loop ileostomy
- segment of bowel approximately 15 cm to the J pouch is chosen and brought through an abdominal incision
- distal limb is stapled and the proximal limb is matured as totally diverting ileostomy
- drains placed in pelvis and perineum and abdomen is closed
17
Q
HNPCC postop? Complication?
A
- Postop
- Flagyl+Lomotil+psyllium followed closely 8 weeks
- Pouchogram at 8 weeks
- if no leak
- closure of the ileostomy 3 months post
- if no leak
- Complications
- soilage (should improve over 12 months)
- anal stenosis (dilation)
- pouch leak (decreased c protective ileostomy and flagyl)
- pouchitis (sudden increase in BMs, tx with oral flagyl after r/o leak)
18
Q
Colorectal cancer HPI?
A
HPI-weight loss, bowel habits, change in stool caliber, blood in stool, consitipation, family history
19
Q
Colorectal cancer PE?
A
PE- abdominal and rectal exam, LN
20
Q
Colorectal Note?
A
- Note-
- multiple synchrounous cancer
- recurrences
- difficult rectal cancer
21
Q
Colorectal imaging/testing?
A
- Imaging/ Test
- biopsy of lesion
- CXR
- CT A/P
- CEA level
- TRUS fo rectal ca (staging)
22
Q
Colorectal staging?
A
- Staging
- Stage 0= Tis
- Stage 1 = T1 (submucosa) ,T2 (muscularis propria)
- Stage 2= T3 (limited to bowel wall/ serosal) ,T4
- Stage 3 = N1
- Stage 4 = MetsTreatment
23
Q
Colorectal treatment? Different locations on the colon?
A
- Treatment
- Bowel prep!
- Stage 1-2 CCA - no chemo
- Stage 3-4 CCA- post op chemo (5FU and leucovorin)
- Stage 3 colon, Stage 2 rectal = neoaduvant radiation
- Colon cancer surgery principles
- Get one vessel above and below (ex for splenic flexure take MCA, Left branch, left colic, first branch of sigmoidrectal artery)
- take mesentery and >12 LN
- margins at least 5-10cm
- Right colon -ligate ileocolic, right colic, right branch of middle colic, remove 5-8cm of ileum to proximal transverse colon
- Proximal transverse- extended Right hemicolectomy and take middle colic and anastomosis between ileum and descending colon
24
Q
Colorectal F/U?
A
- F/u
- colonoscopy q12mo
- CXR q6mo
- office visits q12weeks (CEA, LFT, Stool Guaiac)
- Decrease frequency after 2 years
25
Colorectal cancer postop increase in CEA?
- Situation Increase in CEA?
- repeat CEA in 2 weeks (verify)
- CXR (r/o mets)
- colonoscopy (r/o another can or anastomotic recurrence)
- CT a/p (r/o liver mets, pelvic LN)
- Bone scan
- PET (diff scar tissue from tumor)
- Mult no resectable mets c extra abdominal dz
- chemo and radiation to control symptoms
- intra-abdominal recurrence
- second laparotomy and surgical resection including hepatic mets if (
26
CCA with AAA 8 cm?
- Situation AAA that is 8 cm
| - do this first then the obstructing colon cancer
27
CCA recent MI?
look it up
28
CCA ureteral injury?
look it up
29
CCA path specimen less than 12 LN?
- Path specimen less than 12 LN
| - ask the path to recheck is several times
30
CCA FAP and HNPCC?
- FAP and HNPCC
| - Proctocolectomy c IPAA
31
CCA synchronous?
- Synchronous - subtotal c ileo-rectal anastomosis (IRA) or ileosigmoid
32
CCA locally advanced?
- Locally advanced- En bloc to histological negative margins
33
CCA stage 4?
- Stage 4 - look for s/o IHOP and go to OR if found
| - if no IHOP then preop chemo, if positive liver mets then do liver resection later
34
Splenic flexure colon cancer w.u?
- w/u - CEA, CXR, CT scan
35
Splenic Flexure Colon Cancer presentation?
- carcinoma of the transverse colon (splenic flexure subset) present late and complications (perf, fistula, obstruction) 30-50%
36
Splenic Flexure Colon Cancer involvement of cecal valve?
- Cecal Valve
- Competent- complete bowel obstruction (surgical emergency esp with RLQ pain (cecal dilated) colonoscopy CI) or
- incompetent ileo-cecal valve (decompresses into the small bowel, NGT, rehydrate, e-lytes etc, full w/u and colonoscopy)
- R/O synchronous Lesion
- if unable to scope then can consider barium enema o/w colonoscopy later after hospital stay 6 months
37
Splenic Flexure Colon Cancer paliation?
- colonic stenting for competent valves obstructions for palliation or as a bridge to surgery (high risk pts), reduces m&m and temporary colostomy however surgical management remains relevant as colonic stinting has a small failure rate and isn’t always available
38
Splenic Flexure Colon Cancer margins?
- margins negative 2 cm grossly and 12 LN?
39
Splenic Flexure Colon Cancer cecum is perforated?
- entire lymphovascular pedicles associated c splenic flexure cancer left colic, left branch of middle colic, inferior mesenteric vein
- subtotal if cecum is perforated or synchronous
40
Splenic Flexure Colon Cancer f/u?
- Postop
- aduvant chemo oxalloplatin and FOLFOX for stage III and IV
- Follow up
- 85% recur in 3yrs
- annual CT scan of chest and abdomen for 3 years
- colonoscopy at 3 yrs
- H&P q 3-6mo for 3 yrs and 6mo for 5 yrs
- CEA q3mo for 3yrs
41
Larger Bowel Obstruction from CCA ddx
- obstruction from CA, infection, inflammatory
42
Larger Bowel Obstruction from CCA imaging?
- Imaging
- can see paucity of gas in the distal colon/rectum and small loops not prominent
- (patent cecal valve bad non dilated TI prox to the dilated cecum) no gas bubble- Treatment
- obstructing colon cancer is surgical emergency esp in presence of close loop ( no air in terminal ileum) will perforate
- self expanding metallic stents have no role in tx of tumors that are within the scope of a subtotal colectomy (tumors prox to splenic flexure)
- stents can perforate and usually higher risk (trying to bridge so you can bowel prep etc usually not justified) than just taking the patient back
- intraoperative colonoscopy in stable patient may lead to changes in operative plan 10% synchronous lesions,
- if unable to you need to do a postop 6mo colonoscopy
- best treatment plan for a close loop transverse obstructing Colon Cancer
- intraop colonoscopy
- subtotal colectomy lithotomy position
- if needed do a purse string decompressive colotomy anterior surface proximal right colon can facilitate procedure
- en bloc and remove omentum from greater curvature avoid splenic flexure anastomosis, the descending colon is the ideal location for ileocolic anastomsis
- consider double barrel stoma incorporating TI and corner of proximal colon will avoid anastomotic leakage and allow easy reversal
- primary ileocolic anastomosis should be performed except in HD unstable and gross feculent peritonitis
43
Larger Bowel Obstruction from CCA intraoperative? mets?
- Intraoperative Note- doudenal involvement usually doesn’t require whipple, when feasible primary repair , in more extensive resection RNY recon with doudenojejunostomy may be required
- mets should not be CI to palliative resection but with peritonitis significant mets you may want a stoma or intestinal bypass ??? (need more info) over anastomosis
44
Large bowel obstruction from CCA with mets?
- Situation- in an unstable patient with notable mets
| - should just note it and biopsy and address later
45
Rectal cancer DDx?
- colonoscopy biopsy (if unable to pass scope then needs double contrast barium enema)
- DRE (mobile, relation to anorectal ring (external sphincter),
46
Rectal cancer staging?
- Staging
- CEA, LFTs, CXR, CT scan C/A/P
- ERUS if not obvious T3 or T4 lesion (FNA on suspicious LN)
- T Stage
- T1 invades into Submucosa,
- T2 into muscularis propria Stage 1,
- T3 invades pass the MP into subserosa or into pericolic/rectal tissue,
- T4 invades other organs Stage 2!
47
Rectal cancer PE?
- Lymph nodes DRE
48
Rectal cancer note?
- Note- lesions below the peritoneal reflection = rectal
- Note- when pain is involved indicates involvement of the sphincter by tumor, tumors painful often extend into the external sphincter complex
49
Rectal cancer treatment different stages?
- Treatment
- Stage 1 surgery
- Stage 2,3 neoadj chemoradiation 5FU and radiotherapy for 6 wks rest for 6 wks then surgery. followed by leukovorin 4wks Neoadj tx tolerated better than adjuvant
- after neoadjuvant repeat staging CT CAP oral and IV, proctoscopy to eval response
- preop council - possible diverting stoma, sexual and bladder dysfunction, stool frequenting , urgency 12-24mo
- Neoadjuvant
- decreases local recurrence, inc survival, and can downstage the rectal cancer in 80%
- If rectal mass is fixed 5-FU c XRT 5000Gy (2500Gy if not fixed)
- Surgery 6-8 wks after completion of neoadjuvant tx
50
Rectal cancer transanal excision? description
- Surgery (transanal excision)
- Lithotomy for posterior lesions and prone for anterior lesions
- must be in reach of anal canal and below the peritoneal reflection (upper limit of resection is 6-8 cm from dentate line)
- Lone star retractor to expose anus/rectum
- circumferrential anal block c local and epi to relax sphincter
- place stay sutures 2 cm proximal to lesion in order to facilitate prolapse into the field
- mark 1 cm margins around tumor using Bovie
- incise rectal wall full thickness to perirectal fat maintaining orientation of specimen and mark
- inspect margins
- close defect with absorbable suture
- examine rectal lumen to make sure have not compromised lumen
51
Rectal cancer TME and LAR?
- Surgery (Total Mesorectal excision and LAR)
- Preoperative uretral stents
- mod lithotomy, catheter,
- DRE and proctoscopy to reassess tumor and distal margins
- midline extending from pubis to above the umbilicus ( may extend for splenic flexure mobilization)
- mobilize the sigmoid white line of told, ID ureter, gonadal vessels
- take the IMA after the take off of the left colic (spare this)
- raise the sigmoid mesentery off the retroperitoneum sparing the autonomic nerves
- create avascular plane b/w the visceral and parietal layers of the endopelvic fascia is developed (loose areolar tissue)
- continue posteriorly through Waldeyers fascia (rectosacral fascia S4- rectum) sharply (avoid tearing, bleeding)
- for mid/low rectal cancers dissection is continued to the pelvic floor
- lateral resection sharply c cautery adj to mesorectum avoiding PS nerves
- Pelvic sidewall dissection of the endopelvic fascia is performed
- last is the anterior dissection through or anterior to Denonvilliers fascia removed from the seminal vesicles and upper prostate
- Upper rectal tumors dissect 5 cm distal
- divide mesorectum perpindicular to avoid coning
- 2 cm distal rectal margin is recommended (now 1 cm is sufficient new papers esp with neoadj)
- clamp distal rectum
- double staple technique -rectum is stapled and divided with a linear stapler and tag specimen
- often have to mobilize the splenic flexure- divide IMV adjacent to the LOT and dividing IMA
- chose circular stapler, anvil placed with open bowel c purse string
- anvil is brought into the stapler and connected, closed and anatomosis is created (second staple line)
- inspect the rings (donuts), insufflate the rectum when pelvis is filled with saline to access for air
- Margins 2-5cm distal margins, (2mm)
52
- Patients with early (T1N0M0) without high risk features consider transanal excision
- need 1 cm margins
- you don’t excise LN tissue cuz its just T1
- if unfavorable then LAR vs APR
53
APR description?
- Surgery (APR)
- Suture anus close
- Perform TME as above
- perineal dissection elliptical incision around anus from perineal body to anteriorly to coccyx posteriorly
- Dissection is continued through ischiorectal fat outside of the external sphincters toward coccyx
- anococcygeal ligament is palpated and incised creating space b/w L and R levators
- Divide posterolateral tissues with electrocautery using finger as guide
- once posterior and lateral dissection are completed start anterior dissection
- avoid injury to urethra and bladder during anterior resection men -palpate foley, avoid prostate
- remove specimen
- irrigate and close perineum. if had previous radiation may be wise to c/s PRS preop for assistance with rectus abdominus muscle flap
- close in several layers. put omentum in pelvis. place drain below the peritoneal reflection
- end colostomy and close abdomen
54
F/U and recurrence?
- If recurrence after LAR —> APR if recurrence after APR —> trouble
- foley left for 4-5 days (nerve edema with low dissection) urinary retention
- fecal diversion avoid sequela of leak, difficult anastomosis, prev radiation, blood transfusions
- adjuvant chemo for stage 3 leukovorin 4weeks
- CEA/PE/DRE/Proctoscopy 3-6mo for 2 yrs, and 6mo for 3yrs
- CT CAP yearly for 3 yrs
- Colonoscopy 1 yr and 3yrs later if no polyps
- Stage 4 - options resection and metastectomy c 5FU and leukovorin, resection and chemorads with FULFOX or just palliative chemotherapy without resection
55
Local resection transanal excision criteria?
- Local resection (transanal resection) T1, T2 poorly diff, vascular, lymph invasion then go back for LAR, APR recurrence after these are a death sentence
- if can’t close it pre sacral drain, NPO watch for pelvic abscess
56
Rectal Prolapse note?
Note - secondary to d/o of defecation leading to excessive straining which weakens pelvic floor supportive structures allowing for herniation of bowel, bladder, uterus through the pelvic inlet
57
Rectal Prolapse type?
- 3 types
- Type 1 - prolapse of rectal mucosa only (hemorrhoid like procedure)
- Type 2- prolapse of all layers of the rectal wall (transabdominal rectopexy)
- Type 3- prolapse of all layers of the rectal wall and a sliding perineal hernia usually small bowel (modified altimeier)
58
Rectal Prolapse H&P?
- H/P
- functional status , constipation, incontinence, reducible vs irreducible, bleeding,
- examine perineum/rectum while relaxed and straining
- full thickness (has circumferential folds) vs only mucosa (has radial folds)
- DRE
- eval for rectocele, cystocele
59
Rectal Prolapse imaging, radiology?
- Imaging/Radiology
- BE study or colonoscopy r/o malignancy especially if >40yrs
- anorectal manometry (pt c poor resting tone are unlikely to recover continence c surgery)
- Colonic transit time studies (have patient swallow 24 markers and daily AXR)
- colonic inertia retains 80% of markers at 5 d
- Obstructed defecation will have markers in rectosigmoid junction
- Important because if colon motility d/o exist then pt will likely continue straining and have recurrence after surgery
60
Rectal Prolapse treatment and operations?non op and op?
- Nonoperative mangagement
- best if d/o of defecation
- Fiber supplements and biofeedback tx aimed at appropriate contraction of puborectalis during defecation
- Operative management
- depends on pt surgical risk and degree of prolapse
- Stapled hemorrhoidectomy - mucosal prolapse only
- Transabdominal rectopexy
61
Rectal Prolapse - Transabdominal rectopexy description?
- depends on pt surgical risk and degree of prolapse
- Stapled hemorrhoidectomy - mucosal prolapse only
- Transabdominal rectopexy
- Lower midline incision
- dissect on either side of the peritoneal reflection at the rectosigmoid
- ID and protect ureters
- determine if redundant amount of bowel and if need to resect - may need to wait until after pelvic dissection
- continue pelvic mobilization (no need to mobilize splenic flexure b/c provides some fixation) posteriorly to the coccyx in the pre sacral space (take care not to injure the lateral sympathetic and parasympathetic nerves)
- Laterally don’t dissect below the middle hemorrhoidal vessels
- anterior rectum is dissected to provide additional mobility
- Now dissect redundant sigmoid if necessary and tension free anastomosis
- Pexy rectum to presacral fascia using 4-6 sutures from lateral preserved attachments too pre sacral fascia at level S2-S3
- Can add mesh wrap secured to muscular of rectum and fixed to sacrum
62
- Perineal rectosigmoidectomy (Altmeier) description?
- Perineal rectosigmoidectomy (Altmeier)
- Lithotomy position
- Lone star retractor
- Completely prolapse rectum
- ID dentate line and make circumferential full thickness incision 2-3 cm proximal to dentate line
- Maintain orientation of rectum by placing babcock on anterior aspect
- Anterior wall of hernia sac (peritoneum) is ID and opened at the anterior aspect allowing the rectum to be circumferential freed from the sac
- After rectum is freed the mesenteric attachments and vessels are freed and ligated
- once redundant bowel is completely mobilized , the lax elevator muscles are plicated to provide a snug fit
- Transect redundant bowel and anastomose, hand sewn or stapled c EEA
63
Thrombosed Hemorrhoids ddx?
- DDx- external, internal, perianal abscess, IBD, prolapsed anal polyp, fissure c sentinel tag
64
Thrombosed Hemorrhoids note?
- Note- hemorrhoidal cushions are located R anterior, R posterior and L lateral in anal canal
- hemorrhoids occur when these cushions become engorged or enlarged
- Internal above dentate line and external below
65
Thrombosed Hemorrhoids HPI?
Presents- bleeding, prolapsed, discomfort and rarely pain unless external and thrombosed HPI- bowel habits, constipation, whether prolapsed and reduce or remain out, BPR,
66
Thrombosed Hemorrhoids PE?
- PE- Careful examination of anal canal and proctoscopy
67
Thrombosed Hemorrhoids invasive/radiology?
- Invasive/Radiology- colonoscopy - need to r/o cancers with rectal bleeding, CBC
68
Thrombosed Hemorrhoids internal stages?
- Internal
- 1- bleeding without prolapse ok to band
- 2 (come out but spontaneously return) - ok to band
- 3 (come out and push back)- ok to band if early grade III
- 4 (will not return) extend below the dentate and are too painful for banding, formal hemorrhoidectomy
- avoid resecting too much anoderm can stricture
- dont ID chronic hemorrhoids
- endo suit for sigmoidoscopy
69
Thrombosed Hemorrhoids external thrombosis?
- majority of thromboses hemorrhoids do not need surgery, explain even after surgery they will have pain
- external thrombosis (covered with dry, keratinized normal appearing skin)
- greater than 72 hrs typically swelling get better and no need for incision with proper diet
- if
70
Thrombosed Hemorrhoids medical management?
- Medical management
| - increase fiber intake, water intake to reduce straining
71
Thrombosed Hemorrhoids rubber band ligation? Surgery?
- Rubber band ligation
- careful not to incorporate dentate line - causes pain
- may do 1 to 2 in one session but should wait 4-6 b/w banding
- Surgical hemorrhoidectomy indicated for G3/4
- Jackknife
- 1% lidocaine with epic for local anesthesia - perianal block 4 quadrants
- Hill ferguson retractor
- grasp hemorrhoidal complex with allis clamp
- 3-0 vicryl figure of 8 ligature at base to ligate vascular pedicle
- elliptical incision around complex tapering at anoderm to avoid injury to sphincter
- close wound with running 3-0 chromic suture
- Postop pain is always an issue
- make sure adequate lighting, assistance and exposure
72
Curveballs pt with prosthetic valve and wants banding?
- Patient has inflammatory bowel dz don’t do hemorrhoidectomy
- patient is pregnant- manage non operatively
73
Anal Carcinoma
- Types
- Types
- epidermoid ca (squamous, transitional, mucoepidermoid)
- sarcomas,
- adenocarcinoma,
- melanoma,
- carcinoid
74
Anal Carcinoma 2 regions?
- 2 regions
- Anal canal (squamous epithelial cells) (proximal to anal verge)or b/w puborectalis to the anal verge
- Anal Margin (epidermis lined) (distal to the anal verge) or perianal skin cancers extending out for about 5 cm
- typically treated by WLE and if positive margin then WLE and unable to then Nigro
- anal margin tumors malignant (SCC, BCC, verruocous kaposi) premalignant (Bowens, Pagets, condylomata acuminata)
75
Anal Carcinoma lymphatic drainage?
- Lymphatic drainage
- dentate line
- above dentate line- inferior mesenteric nodes
- below dentate line- superficial inguinal nodes
76
Anal Carcinoma HPI?
- HPI-
| - High risk population HIV, anal or Gyn papillomovirus, last colonoscopy,
77
Anal Carcinoma PE?
- PE-
- check inguinal LN, DRE any induration, masses, ulcerations
- sometimes present like anal fissures, fistulas, pruritus ani
78
Anal Carcinoma invasive/radiology?
- Invasive/ Radiology
- needs anoscopy and biopsies
- colonoscopy and proctoscopy biopsies
- EUS if positive and CT r/o mets, if palpable groin LN needs FNA
- CXR, CT C/A/P, LFT, CBC, PT/PTT
79
Anal Carcinoma note?
- Note- Nigro protocol- high response rate and preservation of sphincters
80
Anal Carcinoma nigro protocol?
- Nigro protocol Squamous of the anal canal and (adenocarcinoma inv sphincters)
- 4 weeks 5FU, Mitomycin, XRT 4000 rads (if inguinal region is + for Cancer then radiate that as well (same efficacy as a dissection but less morbidity)
- 6weeks off and Bx could wait up to 12 weeks to let take full effect
- if + 4 weeks 5FU, Mitomycin, XRT 4000 rads
- 6 weeks off
- if + APR
- F/U surveillance inguinal node and anoscopy (topical acetic acid survey HPV related dysplasia Bx q3mo for 2yrs and q6mo for 3 yrs,
- if T3 or N1 then annual CT CAP
81
Anal Carcinoma anal margin?
- Anal margin-
- SCC -WLE 1 cm, BCC excise c clear margins, Cloacogenic and transitional and basaloid cancers (epidermoid ca) =treat like SCC
- Melanoma tx c WLE if depth is only submucosa, XRT is saved the sphincters, if any disease is left behind then —>APR distant mets the survival is dismal chemo may not even help
- adenocarcinoma not invading sphincters tx WLE o/w Nigro protocol
- Sarcoma- malignant if >5 mitosis/50 HPF —> APR and residual tx XRT
- Bowens (SCC insitu) and Pagets (adeno insitu)- tx WLE
- Kaposi- XRT
82
Anal Carcinoma APR?
- APR (sometimes palliative)
- indication- incontinence, malignant fistula, intractable pain should have APR c neo and adjuvant chemoradiation
- same as a LAR except add the perineal dissection as well
- Dissect posteriorly outside the external sphincter muscle toward the tip of the coccyx
- free the rectum laterally both sides
- anteriorly the posterior of the (vagina/prostate) is kept anterior to rectum
- specimen is freed and removed via the perineal opening
- closed in layers (or myocutaneous flap)
- close perineum over a drain via perineum
- omentum is placed in the pelvis and mature ostomy
- grossly close margins can be sent as frozens
83
Anastomotic leak after Colectomy when?
- many early leaks can be readily dx clinically and prompt tx early do barium enema later do CT scan more accurate
84
Anastomotic leak after Colectomy r/o?
- r/o uti, infxn, PNA
85
Anastomotic leak after Colectomy problems with CT scan?
- CT scan can show free air for 10d and localized air 30days
86
Anastomotic leak after Colectomy before 5 days?
early leaks within 5 days most of the time require return trip avoid the temptation to just stitch cuz if it leaked in the most ideal situation much more likely to leak in emergency, inflamed circumstances (perfume on the pig)
87
Anastomotic leak after Colectomy later 7-10 days?
- later 7-10 d really inflamed tissue, friable tissue, ileum can be disastrous and do more damage and requiring stomas, longer you wait the more difficult it will be
88
Anastomotic leak after Colectomy should remember when doing surgery?
- remember if you resect and anastomosis place a loop ileostomy ( mark a stoma sitting and standing avoid crease)
- can sometimes manage leaks c perc drain, abx, nonop
89
Anastomotic leak after Colectomy type of surger?
- Surgery
- Right hemi ok to resect and anastomosis with loop if stable , HD, minimal contamination
- Left hemi need more caution usually require fecal diversion end stoma
- leave a drain
- lithotomy to test anastomosis betadine
- obese patients make stoma higher up to avoid pannus
- ABX goal oriented manner
90
Ogilvies Syndrome patient type?
- 80-90 yr Nursing home patient
91
Ogilvies Syndrome HPI?
- HPI- painless colinic dilation, abdominal distension, obstipation, constipation, diarrhea, nausea, vomiting
- r/o meds narcotics, tricyclic antidepressants, clonidine, anti-Parkinsons meds
92
Ogilvies Syndrome PE?
- PE- r/o peritonitis, rectal exam to r/o mass or impaction
93
Ogilvies Syndrome Dx?
3 view X-ray to r/o free air, obstruction, evaluate dilation of colon and presence of air in rectum, check size of cecum (>10 is concerning)
94
Ogilvies Syndrome labs?
routine
95
Ogilvies Syndrome
- Treatment
| -
96
Ogilvies Syndrome no improvement in 24hrs?
- Fails —>
- if no improvement in 24 hrs after the above management
- then move to monitored bed and give neostigmine (2mg over 3min watch out for bradycardia and have atropine ready)
- Erythromycin my stimulate motilin receptors and help colon move
- Fails—>
- If still no improvement or the cecum is >10 cm then perform a colonoscopic decompression (without insufflation) leaving rectal tube
- obtain a procedure xray
- Fails —> the patient develops peritonitis or cecum is >10 cm after colonoscopy or gangrene seen on colonoscopy
- Operation is indicated
- Right hemicolectomy with end ileostomy and MF
- Loop colostomy with endoscopic decompression
- Severely ill patient w/o evidence of cecal necrosis a cecostomy tube can be used
97
Colonic volvulus note? RF? Pregnant?
- RF-constipation chronic or psych
- MC obstruction in female pregnant
- close loop obstruction sigmoid, cecum
98
Colonic volvulus HPI?
- Feculent vomiting if incompetent ileocecal valve
99
Colonic volvulus PE?
- abdomen and rectum and access vital signs
100
Colonic volvulus Dx?
- 3 view X-ray
- bent inner tube or omega sign of the counter clockwise sigmoid volvulus verses the coffee bean of the CW cecal volvulus
- CT swirl
- Barium enema - birds beak (barium is CI due to risk perforation I would skip it and go to CT)
101
Colonic volvulus labs?
routine
102
Colonic volvulus treatment?
- NPO, IVF, Foley, ABX, NGT
- stable patient-endoscopic decompression (rigid sigmoidoscopy) and rectal tube followed by hydration and e-lyre and then OR (esp in elderly)
- o/w go to the OR open (especially if necrosis is seen)
- prior to detorsion of volvulus the mesentery should be divided to prevent circulation of inflammatory cytokines
- even in successfully decompressed patients still do an elective sigmoidectomy
- anastomosis will depend on conditions sometimes in unprep colon just do the sigmoidectomy
- pregnancy without peritonitis
- first trim-non op decompression
- 2nd trim sigmoid colectomy
- 3rd trimester non op decompression and deliver and then surgery
- sigmoid volvulus- sigmoid colectomy
- cecal volvulus- right hemicolectomy
- unless frail then do a right hemicolectomy and end ileostomy and MF
- no cecopexy placing suture in a distended thinned cecal wall bad
103
Colonic volvulus leaktest?
- leak test
- fill pelvis with sterile saline and compress the bowel proximal to the anastomsi and insufflate the rectum with air using a rigid sigmoidoscope and check for bubbles
- patients with end ileostomy (cecal volvulus) must wait at least 6-12 weeks
104
Complicated diverticulitis signs?
- LLQ pain, fever, wbcs
105
Complicated diverticulitis CT scan?
- triple contrast CT
106
Complicated diverticulitis pitfalls?
pitfall of emergency setting is to attempt resect entire sigmoid colon with aim of treating diverticular disease. requires splenic mobilization and entry into pelvis for creation of colorectal anastomosis and expose previously unaffected tissue planes to the infectious process and postoperative abscess adds also about 40 minutes to the case as opposed to hart mans. may be considered in a HD stable and Hinchey 1 or 2
107
Complicated diverticulitis surgery?
- Surgery
- divide mesocolon close to bowel wall leaving IMV, inferior and superior rectal arteries undisturbed and divide sigmoid colon above pelvic brim
- if cancer than do a high ligation of the inferior mesenteric artery
- could consider a hart mans which eliminates the risk of anastomotic leak and postop abscess which would delay chemc
- crohns- limited resection of perf colon with end colostomy, total abdominal colectomy with end ileiostomy, or TAC with ileorectal anastomosis and proximal diverting loop ileostomy
108
Complicated diverticulitis prolong ileus?
prolonged ileus, nonfunctioning stoma, persistent fever or wbc suspect leak, CT drainage of abscess is typically successful in managing sepsis. wound infxn are common with hartmans just remove clips local wound care
109
Complicated diverticulitis note?
- can also see if can place a perc drain and avoid surgery take ctrl of sepsis and convert an emergent to an elective case
- herniation of mucosa and submucosavia muscular weakness in bowel
- 1% have complications that need surgery
- generalized peritonitis needs resuscitation, broad spectrum abx, surgery exploration
- std care with complicated diverticulits who need urgent surgery is hartmans
- Hinchey 1 pericolonic abscess or 2 pelvic absess can consider sigmoid resection with colorectal anastomsis and proximal diversion
- Hinchey 3 purulent dz or 4 feculant peritonitis Hartmans
- rare complicated cases with severe inflammation or surrounding structures or patients unstable during the operation it is necessary to perform proximal diversion without resection leaving abdominal and pelvic drains to control sepsis
110
Ischemic Colitis HPI?
- crampy abdominal pain followed by bloody diarrhea
111
Ischemic Colitis ct results?
- CT will show thickening
112
Ischemic Colitis diagnositic?
unprepped Colonoscopy c biopsies unless evidence of peritonitis - test of choice to diagnose -erythema,ulcers near splenic flexure-if grey or black terminate c/s; - check stool cx c.diff toxin
113
Ischemic Colitis angio?
- angio rarely indicated unless acute small intestinal mesenteric ischemia suspected
114
Ischemic Colitis SMA, IMA?
- SMA-middle colic, right colic, ileocolic IMA-left colic artery, superior hemorrhoidal artery
115
Ischemic Colitis MC location?
- MC splenic flexure, descending and sigmoid colon
116
Ischemic Colitis surgery?
- most respond to hydration, bowel rest, broad spectrum abx
- peritonitis , evidence of perforation or clinical deterioration should prompt immediate surgery
- resect compromised colon primary anastomosis vs stoma
- pt with right sided ischemia need surgery more frequently and have worse outcomes
- Surgery - when fails to improves or has peritonits
- when in doubt intraoperative colonoscopy, palpation, doppler assessment of colonic vests and IV fluorescein
- may have to do a second look
- need brisk bleeding at bowel ends
117
Ischemic Colitis after aortic surgery?
- ischemic bowel after aortic surgery-disruption of IMA, also cross clamping of aorta and HD unstable, may have to reimplant IMA if SMA is stenotic and collateral blood supply inadequate to supply left colon-symptoms abdominal pain bloody diarrhea fever- if colonic resection is necessary then a primary anastomosis should be avoided as a anastomotic leak risks graft contamination!
- 3-6 mo for colostomy TD
118
Medically Refractory Ulcerative Colitis surgical treatment?
- surgical tx for medically refractory UC - TNF agent, infliximab
119
Medically Refractory Ulcerative Colitis symptoms?
- surgical tx for medically refractory UC - TNF agent, infliximab
120
Medically Refractory Ulcerative Colitis PE?
- PE -rectal abdomen
121
Medically Refractory Ulcerative Colitis sigmoidoscopy?
- sigmoidoscopy- send stool for C&S, c.diff, r/o crohns
122
Medically Refractory Ulcerative Colitis indications for surgery?
- review doc, prior c/s, path, radiographic evidence to r.o crohns (ask about anorectal surgery abscess fistula dz)
- anal sphincter intergity
- Prior to surgery medical tx optimized including r/o superimposed infectious colitis 30% of the time
- misconception is that surgery is inevitable for severe UC, only 30% undergo surgery
- indications- toxic megacolon (distended, fever, wbc, >10 BM/d, continous bleeding, transfusion requirements, hypoalbuminemia, radio graph evid wall thickening possible dilation)
- stool samples c.diff toxin and antigen and colonoscopy biopsies for CMV
- evaluate for toxic colitis and crohns dz
- consider 3 stage approach with initial subtotal colectomy of ill patients, or significant anti TNF agents , high does steroids ass with higher complications rates, avoid pelvic dissection and maintain virgin planes for the next surgery
- ileal pouch anal anastomosis c diverting loop ileostomy -MC surgery for UC vs total proctocolectomy with end ileostomy and
- be prepared for lengenthing procedure and alternative pouch
- j pouch 90% overall success rate
123
Medically Refractory Ulcerative Colitis surgery IPAA for crohns dz?
- Surgery IPAA (CI crohns)
- mod lithotomy assess to anus
- total proctocolectomy or finish proctectomy divide mesentery near the bowel unless cancer concern
- staple and divide the TI preserving the ileocolic artery initially
- double staple tech- TA-30 to staple anorectal jxn at level of levator muscle
- mobilize small bowel and its mesentery LOA and separate superior mesenteric a pedicle from 3rd portion of doudenum
- if insuff length then divide peritoneum, selective vascular ligation or alt pouch, transluminate to verify blood supply, usually ileocolic artery ligation will allow sufficient length (use bulldog clamp to test blood supply first)
- create 15-20 cm long j-pouch staple distal two limbs of ileum together with GIA stapler and insert anvil EEA for double staple tech
- perform anastomosis
- divert loop ileostomy
124
Medically Refractory Ulcerative Colitis postop leak, long term complication? f/u?
- postop leak - comb of abx, perc drain, diverting ileostomy and open washout depending on situation
- long term comp IPAA- pouchitis, bowel obstruction, female infertility,
- freq bowel movements not a complication but expected functional outcome need to prepare patient for this along with nighttime leakage
- f.u dysplasia rec 8-10 yrs after onset of UC
125
Crohn’s Disease with small bowel stricture ddx? Findings?
- DDX-appy, IBD, infectious enterocolitis campylobacter and Yersenia, ovarian torsion, tubal ovarian abscess, PID, ectopic pregnancy
- narrowed segment of TI, rectal sparing
- can be unremitting and is incurable (surgery for sx only)
- discontinous, full thickness, and where GI, etiology uncertain, smoking increases recurrence
- ileocolic dz 40%, small bowel isolated colon dz, gastrodoudenal dz
- inflammatory, stricturing, fistulizing
126
Crohn’s Disease with small bowel stricture CT scan purpose?
CT scan good choice to r/o abscess, obstruction, perforation, thickened colon, adjacent organ involved, fistulas, phlegmon, colovesical fistula or enterovesical
127
Crohn’s Disease with small bowel stricture small bowel study?
- small bowel contrast studies useful for small bowel thats proximal to TI
128
Crohn’s Disease with small bowel stricture endoscopy?
- endoscopy is critical in management of CD c biopsies however careful in acute settings may want to avoid, c/s should intubate TI
129
Crohn’s Disease with small bowel stricture medical treatment?
- stricture in newly diagnosed CD patient is likely inflammatory as opposed to chronic CD fibrostenotic. - so medical tx first aminosalicylates, abx, , steroids, anti-TNF agent
130
Crohn’s Disease with small bowel stricture obstruction?
- obstructive NGT, bowel rest
131
Crohn’s Disease with small bowel stricture abscess?
- abscess needs perc drain
132
Crohn’s Disease with small bowel stricture when surgery?
- surgery if persistent sx delayed in an elective setting (helps avoid the bleeding in acute inflammation and preserve bowel length
- since surgery not curable only use for complications and alleviate sx (IHOP)
- med refractory, med related comp, mass hemorrhage, free perf, acute obstruction, neoplasia, abscess unable to be perc drained, symptomatic fistula
- most common indication is stricture
- resect, stricturoplasty, bypass technique
- if long isolated segment of structured TI, ileocolic resection is recommended
- eval entire bowel, lateral to medial or medial to lateral mobilization of the ascending colon and mesentery depending amount of inflammation
- ID doudenum
- ligate and divide iloecolic vessels
- divide bowel based on gross dz, anastomsis ileum to ascending colon
- aminosalycilates abx modestly effective prevent recurrence, anti TNF for severe dz and avoid smoking
133
Fulminant Clostridium difficile Colits HPI?
- Acute onset of profuse diarrhea think infectious
| - abx and watery diarrhea think c.diff
134
Fulminant Clostridium difficile Colits endoscopy?
- endoscopy can be used but not good idea if possible perf
135
Fulminant Clostridium difficile Colits labs?
stool sent for cx and ova and parasites. enzyme immunoassay is sent for c.diff toxin and empiric PO metro high suspicion and stop broad spectrum abx!
136
Fulminant Clostridium difficile Colits medical treatment?
- medical care possible ICU care depending and PO vanco and IV metro and serial abdominal exams, imaging
- fulminant colitis =severe systemic and toxic megacolon
137
Fulminant Clostridium difficile Colits mortality rate?
50%
138
Fulminant Clostridium difficile Colits indications for surgery?
- indications for surgery (total abdominal colectomy c end ileostomy) not procto cuz too much dissection
- if patient remains unstable or fails to improve in 24-48hrs
- MSOF, requiring vasopressors, vent support
139
Fulminant Clostridium difficile Colits surgery?
- SUrgery
- mod lithotomy allows for proctoscopy eval rectal mucosa
- care entering cuz large colon, inspect entire bowel
- won’t likely tolerate a second laparotomy and likely hood of pancolonic involvement do a TAC
- transect distal ileum and mesentery and divide ileocolic, right, middle, left colic and sigmoid vessels
- divide whole sigmoid colon at pelvic brim and oversew rectal stump
- rare to have to resect rectum 2/2 disease
- damage ctrl if extremely unstable left open after colon resection and return to ICU for resuscitation, then 24-48hrs return for closure and maturation of ileostomy
140
Radiation Enteritis/ Proctitis note?
- Note
- affects up to 70% of patients with pelvic irradiation
- path of chronic radiation damage is obliterative endarteritis causing ischemia and fibrosis
- bowel is stiff, pale and noncompliant
- RF 65 Gy radiation
141
Radiation Enteritis/ Proctitis forms?
- forms
- acute (w/in weeks)
- chronic
142
Radiation Enteritis/ Proctitis HPI?
- nausea, diarrhea, abdominal pain, tenesmus, cramping BRBPR
143
Radiation Enteritis/ Proctitis imaging?
i- maging
- AXR,
- CT A/P to r/o abscess or original malignancy
- UGIS (to access extent of disease strictures)
- Scope?
144
Radiation Enteritis/ Proctitis treatment?
- Treatment/Operations
- mainly medical
- low residue diet, low fat, NPO in acute phase, consider TPN when fistulas
- may consider steroids to blunt inflammatory response
- If you have to operate be conservative
- done on complicated cases (obstruction, non-healing fistulas)
- resect only involved bowel only if safe o/w bypass it
- consider bypass instead of resection and anastomosis, stricturoplasty, ostomy
- send F.S to verify healthy bowel prior to anastomosis
145
Radiation Proctitis problems?
- more resistent to radiation than small bowel but fixed position makes it particularly vulnerable 2/2 to proximity of other organs irradiated
- dose dependent
- most wil resolve and are self limited
146
Radiation Proctitis chronic?
- chronic proctitis occurs >1 year after andrectum is pale and noncompliant
147
Radiation proctitis PE?
- may bleed heavily, painful,
- PE
- rectum is erythematous, inflamed, c superficial mucosal sloughing and ulceration
148
Radiation Proctitis treatment?
- Treatment/Operations
- Hydration, antidiarrheals, mesalamine/ steroid enemas
- if resistant and still symptomatic need to consider
- fistula-cystoscopy
- recurrence of malignancy -biopsy
- continue medical management
- Argon or infrared coagulation consider laser ablation of bleeding mucosa (90% success in some studies)
- Formalin therapy (high success rate but can cause strictures)
- If continued problems - diverting colosotomy + medical support
- If massive hemorrhage that can’t be controlled- may need emergent APR
149
Fistula in Ano what is it?
- Abnormal connection b/w anal canal/rectum and perianal skin
150
Fistula in Ano types?
- Intersphincteric (MC)
- transphincteric
- Suprasphincteric
- Extrasphincteric
151
Fistula in ano goodsall rule?
- Goodsall rule
- anterior external openings will take straight radial course
- posterior fistulas will take a circumferential course to originate in the posterior midline
152
Fistula in Ano H&P?
- Pain, length of time, purulent drainage, H/O crohns, previous fistulas
153
Fistula in Ano invasive radiology?
- Anal and rectal exam
| - EUA/ proctoscopy
154
Fistula in Ano treatment and operation? EUA, Fistulotoomy,
- EUA
- need to define anatomy
- place lacrimal probe into external opening in order to delineate the internal opening and tract
- can also inject with methylene blue or hydrogen peroxide
- try to determine location of fistula with respect to external anal sphincter
- where is the internal opening in relation to anorectal sphincter (easier to ID when pt tightens sphincter)
- if you cute >50% of posterior or 30% anteriorly increase risk of incontinence
- cutting the internal sphincter carries practically no risk of incontinence
- Fistulotomy
- Distal
- if less
155
Fistula in Ano advancement flap, collagenn plug?
- Advancement flap
- U shaped flap consisting of mucosa/submucosa/fibers of internal sphincter is raised starting at the internal fistula opening and moving
- Fistula tract is the curetted and closed with 2-0 vicryl suture
- Flap is then advanced caudally over the internal opening and sutured in place with 3-0 chromic
- may drain external opening
- Collagen plug (surgisis plug)
- placed through fistula openings, taking care to avoid enlarging the fistula
- sutured in place within rectum c 2-0 vicryl, excess is trimmed
156
Rectovaginal fistula causes?
- majority from obstetric trauma - episiotomy, forceps delivery
- second MC is from inflammatory bowel dz
- radiation, diverticulitis, trauma, FB, cancer, previous LAR, hysterectomy
157
Rectovaginal fistula H&P?
- previous surgery, fecal incontinence, IBD, obstetric hx
- Access sphincter tone, bimanual vaginal exam, speculum, anoscopy
- if can’t see confirm with methylene blue enema and tampon in vagina
158
Rectovaginal fistula invasive/radiology?
- anorectal manometry
- transanal u/s
- pudendal nerve terminal motor latency in order to assess sphincter function
- CT scan to delineate more proximal fistula
159
Rectovaginal fistula classification?
- Low/Simple- secondary to birth trauma
| - High/ complex - usually mandating transabdominal repair, fecal diversion before repair
160
Rectovaginal fistula treatment? Low fistula
- if immediately postpartum wait 3 months to allow inflammation to resolve prior to repair
- drain any abscess or collections- may use non cutting setoffs- vessel loops
- Low fistula - transanal repair
- endorectal Advancement Flap-
- ID fistula
- outline trapezoidal incision containing fistula at the apex
- flap should contain mucosa/submucosa.circular layer of muscle
- after fistula is exposed curette tract removing granulation
- mobilize and close the internal sphincter over the tract
- close tract c 3-0 vicryl
- no need to close vaginal opening as the high pressure zone of the rectum has been treated
- post op - sit baths, stool softness, high fiber
- Note- used in crohns if in remission
- Other options
- surgisis plug, fibrin glue, staged fistulotomy
- Plication Sphincteroplasty
- used if there is an associated anal incontinence
161
Rectovaginal fistula transperineal procedure?
- involve incision of perineal body, involve dissection b/w rectal and vaginal mucosa
- options
- layered closure
- not good cuz divides sphincters and leads to incontinence
- repair with interposition
- martius graft-involves bulbocavernosus and labial fat pad interposition
162
Rectovaginal fistula complex?
- Complex
- Abdominal procedures
- treat diseased organ and always interpose viable tissue to prevent recurrence i.e. omentum
- the problem is not the vagina but with the other organs
- often requires fecal diversion especially to tx sepsis/abscess
- if associated with abscess or infection then best to resect affected segment of rectum
163
Fecal Incontinence Post Obstetric or Sphincterotomy treatment?
- be conservative at first (most improve over 6 mo period of observation and local care
164
Fecal Incontinence Post Obstetric or Sphincterotomy symptoms persist?
- if symptoms persist
- order anal manometry (document decreased sphincter fxn)
- EUS (ID internal and external sphincter defects)
- Pudendal nerve latency testing to determine nerve fxn (can help in neurogenic incontinence but not in sphincter injuries)
- If test are positive consider plication of sphincteroplasty
- Lithotomy
- Semicircular incision anterior to anus and dissecting in submucosal plane
- Elevate anoderm to expose attenuating internal sphincter
- Continue lateral dissection to find transverse perineal muscle bilaterally
- avoid too lateral of dissection to avoid injuring pudendal nerves
- Continue dissection deep to internal sphincter to ID the levators
- Approximate the levators with 3-4 sutures,
- Overlapping (plicate) the transverse perineal muscle in the midline
- plicate the internal sphincter in the midline
165
Fecal Incontinence Post Obstetric or Sphincterotomy complications?
- Complications
- Anal stenosis-high bulk diet, dilation or if not successful can try Y-V advancement flap
- Local sepsis- tx local maneuvers
166
Anal Fissures notes?
- Painful linear ulcer of squamous epithelium extending from the dentate line to the anal verge
- MC (90%) posterior midline
- 2/2 hypertonic sphincter and decreased blood flow leading to poor wound healing
167
Anal Fissures H&P?
- Sudden onset of sharp pain initiated c passage of stool that persists for hrs and associated with BRBPR
168
Anal Fissures treatment?
- Usually medical
- topical CCB, Fiber, Hydration, Sitz, Stool softners, topical anesthetics
- Sometimes botox
- Lateral internal Sphincterotomy (except in crohns)
- prone jackknife position
- 1 cm incision in left lateral aspect of anal verge (make sure in perianal skin)
- grasp internal sphincter with allis clamp
- divide internal sphincter to proximal extent of fissure
169
Anal abscess r/o?
- h/o rectal problems, abscesses, fistulas, crohns or UC, recent surgery, trauma
170
Anal abscess ddx?
pilonidal cyst, sebaceous cyst, perihydradenitis supportiva (rarely limited to anal region, chronic pain, swelling, drainage), hemorrhoids, fissures, IBD these won’t have WBC
171
Anal abscess HPI?
- did it just pop up (infected anal gland)
- try a rectal exam in office
- acute anal pain and swelling are not trivial but need urgent attention (could be a horseshoe abscess)
172
Anal abscess treatment?
- admit to day surgery rigid proctoscopy r/o fistula or bulging abscess in rectal vault, treatment is emergent not elective for abscess
- perianal abscess (painful, unlikely to cause serious sequelaie), periRECTAL, ischoRECTAL (high morbidity and life threatening if tx is delayed) no outward visible sign tenderness on DRE on anal canal
- perianal abscess is readily visible easily palpable doesn’t give rise systemic infection
- ishiorectal can penetrate through the external sphincter and develop into the larger ishio rectal fossa - fevers, WBC, sepsis, medial buttock erythematous deeper abscess
- lack of pain on rectal exam is reassuring that a high or deep abscess is not present
173
Anal abscess unexplained rectal pain?
- unexplained rectal pain and s/o infxn get a CT cuz could be supralevator or occult abscess
174
Anal abscess EUA?
- should be done if any question of occult or complicated abscess
175
Anal abscess CT?
- if suspect supralevator abscess
176
Anal abscess difficult to FNA?
- failure to aspirate c FNA could mean too thick so do dx incision incision should be generous c removal of overlying skin to promote adequate drainage elliptical, debridement, cultures
177
Anal abscess acute inflammation?
- dont do fistulotomy in face of acute inflammation, place setons if a fistula is obvious
- use plain moist gauze packing and leave initial packing for 48 hrs
178
Very large abscess?
- if abscess is large and or deep place Malecot drain sutured into place
179
Anal Abscess general rule acutely?
general rule is I&D should be done in the OR unless superficial and small, inject into the dermis not subcutaneous tissue, tangential elliptical incision to the anus, small wick of moisten gauze (iodoform is harsh)
180
Horseshoe abscess?
- Horseshoe abscess
- tangential incision or circumfrential incsion, multiple small incisions small malecot catheter and simple packing and remove in 24-48 hrs or longer for larger abcess
181
Anal Abscess f/u?
- close f/u cuz a small abscess may have been missed
182
Anal abscess surgery and follow up?
- close f/u cuz a small abscess may have been missed
- fistula - lacrimal probe, hydrogen peroxide through fine cannula into external opening, if acute inflammation just leave a seton
- sphincter length should be known prior to anesthesia posterior anal canal distance to levator ring to anal verge (2-5cm) preserve 2 cm anal sphincter with fistulotomy
- sitz baths, high fiber diet, stool softeners
