Colon and Rectum Flashcards

Question

Colorectal cancer postop increase in CEA?

Answer 1

- 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 (

Answer 2

- Situation AAA that is 8 cm | - do this first then the obstructing colon cancer

Answer 3

look it up

Answer 4

look it up

Answer 5

- Path specimen less than 12 LN | - ask the path to recheck is several times

Answer 6

- FAP and HNPCC | - Proctocolectomy c IPAA

Answer 7

- Synchronous - subtotal c ileo-rectal anastomosis (IRA) or ileosigmoid

Answer 8

- Locally advanced- En bloc to histological negative margins

Answer 9

- 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

Answer 10

- w/u - CEA, CXR, CT scan

Answer 11

- carcinoma of the transverse colon (splenic flexure subset) present late and complications (perf, fistula, obstruction) 30-50%

Answer 12

- 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

Answer 13

- 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

Answer 14

- margins negative 2 cm grossly and 12 LN?

Answer 15

- 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

Answer 16

- 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

Answer 17

- obstruction from CA, infection, inflammatory

Answer 18

- 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

Answer 19

- 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

Answer 20

- Situation- in an unstable patient with notable mets | - should just note it and biopsy and address later

Answer 21

- colonoscopy biopsy (if unable to pass scope then needs double contrast barium enema) - DRE (mobile, relation to anorectal ring (external sphincter),

Answer 22

- 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!

Answer 23

- Lymph nodes DRE

Answer 24

- 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

Answer 25

- 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

Answer 26

- 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

Answer 27

- 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)

Answer 28

- need 1 cm margins - you don’t excise LN tissue cuz its just T1 - if unfavorable then LAR vs APR

Answer 29

- 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

Answer 30

- 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

Answer 31

- 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

Answer 32

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

Answer 33

- 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)

Answer 34

- 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

Answer 35

- 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

Answer 36

- 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

Answer 37

- 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

Answer 38

- 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

Answer 39

- DDx- external, internal, perianal abscess, IBD, prolapsed anal polyp, fissure c sentinel tag

Answer 40

- 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

Answer 41

Presents- bleeding, prolapsed, discomfort and rarely pain unless external and thrombosed HPI- bowel habits, constipation, whether prolapsed and reduce or remain out, BPR,

Answer 42

- PE- Careful examination of anal canal and proctoscopy

Answer 43

- Invasive/Radiology- colonoscopy - need to r/o cancers with rectal bleeding, CBC

Answer 44

- 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

Answer 45

- 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

Answer 46

- Medical management | - increase fiber intake, water intake to reduce straining

Answer 47

- 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

Answer 48

- Patient has inflammatory bowel dz don’t do hemorrhoidectomy - patient is pregnant- manage non operatively

Answer 49

- Types - epidermoid ca (squamous, transitional, mucoepidermoid) - sarcomas, - adenocarcinoma, - melanoma, - carcinoid

Answer 50

- 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)

Answer 51

- Lymphatic drainage - dentate line - above dentate line- inferior mesenteric nodes - below dentate line- superficial inguinal nodes

Answer 52

- HPI- | - High risk population HIV, anal or Gyn papillomovirus, last colonoscopy,

Answer 53

- PE- - check inguinal LN, DRE any induration, masses, ulcerations - sometimes present like anal fissures, fistulas, pruritus ani

Answer 54

- 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

Answer 55

- Note- Nigro protocol- high response rate and preservation of sphincters

Answer 56

- 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

Answer 57

- 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

Answer 58

- 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

Answer 59

- many early leaks can be readily dx clinically and prompt tx early do barium enema later do CT scan more accurate

Answer 60

- r/o uti, infxn, PNA

Answer 61

- CT scan can show free air for 10d and localized air 30days

Answer 62

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)

Answer 63

- 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

Answer 64

- 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

Answer 65

- 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

Answer 66

- 80-90 yr Nursing home patient

Answer 67

- HPI- painless colinic dilation, abdominal distension, obstipation, constipation, diarrhea, nausea, vomiting - r/o meds narcotics, tricyclic antidepressants, clonidine, anti-Parkinsons meds

Answer 68

- PE- r/o peritonitis, rectal exam to r/o mass or impaction

Answer 69

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)

Answer 70

- Treatment | -

Answer 71

- 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

Answer 72

- RF-constipation chronic or psych - MC obstruction in female pregnant - close loop obstruction sigmoid, cecum

Answer 73

- Feculent vomiting if incompetent ileocecal valve

Answer 74

- abdomen and rectum and access vital signs

Answer 75

- 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)

Answer 76

- 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

Answer 77

- 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

Answer 78

- LLQ pain, fever, wbcs

Answer 79

- triple contrast CT

Answer 80

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

Answer 81

- 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

Answer 82

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

Answer 83

- 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

Answer 84

- crampy abdominal pain followed by bloody diarrhea

Answer 85

- CT will show thickening

Answer 86

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

Answer 87

- angio rarely indicated unless acute small intestinal mesenteric ischemia suspected

Answer 88

- SMA-middle colic, right colic, ileocolic IMA-left colic artery, superior hemorrhoidal artery

Answer 89

- MC splenic flexure, descending and sigmoid colon

Answer 90

- 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

Answer 91

- 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

Answer 92

- surgical tx for medically refractory UC - TNF agent, infliximab

Answer 93

- surgical tx for medically refractory UC - TNF agent, infliximab

Answer 94

- PE -rectal abdomen

Answer 95

- sigmoidoscopy- send stool for C&S, c.diff, r/o crohns

Answer 96

- 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

Answer 97

- 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

Answer 98

- 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

Answer 99

- 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

Answer 100

CT scan good choice to r/o abscess, obstruction, perforation, thickened colon, adjacent organ involved, fistulas, phlegmon, colovesical fistula or enterovesical

Answer 101

- small bowel contrast studies useful for small bowel thats proximal to TI

Answer 102

- endoscopy is critical in management of CD c biopsies however careful in acute settings may want to avoid, c/s should intubate TI

Answer 103

- 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

Answer 104

- obstructive NGT, bowel rest

Answer 105

- abscess needs perc drain

Answer 106

- 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

Answer 107

- Acute onset of profuse diarrhea think infectious | - abx and watery diarrhea think c.diff

Answer 108

- endoscopy can be used but not good idea if possible perf

Answer 109

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!

Answer 110

- medical care possible ICU care depending and PO vanco and IV metro and serial abdominal exams, imaging - fulminant colitis =severe systemic and toxic megacolon

Answer 111

- 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

Answer 112

- 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

Answer 113

- 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

Answer 114

- forms - acute (w/in weeks) - chronic

Answer 115

- nausea, diarrhea, abdominal pain, tenesmus, cramping BRBPR

Answer 116

i- maging - AXR, - CT A/P to r/o abscess or original malignancy - UGIS (to access extent of disease strictures) - Scope?

Answer 117

- 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

Answer 118

- 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

Answer 119

- chronic proctitis occurs >1 year after andrectum is pale and noncompliant

Answer 120

- may bleed heavily, painful, - PE - rectum is erythematous, inflamed, c superficial mucosal sloughing and ulceration

Answer 121

- 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

Answer 122

- Abnormal connection b/w anal canal/rectum and perianal skin

Answer 123

- Intersphincteric (MC) - transphincteric - Suprasphincteric - Extrasphincteric

Answer 124

- Goodsall rule - anterior external openings will take straight radial course - posterior fistulas will take a circumferential course to originate in the posterior midline

Answer 125

- Pain, length of time, purulent drainage, H/O crohns, previous fistulas

Answer 126

- Anal and rectal exam | - EUA/ proctoscopy

Answer 127

- 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

Answer 128

- 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

Answer 129

- majority from obstetric trauma - episiotomy, forceps delivery - second MC is from inflammatory bowel dz - radiation, diverticulitis, trauma, FB, cancer, previous LAR, hysterectomy

Answer 130

- 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

Answer 131

- anorectal manometry - transanal u/s - pudendal nerve terminal motor latency in order to assess sphincter function - CT scan to delineate more proximal fistula

Answer 132

- Low/Simple- secondary to birth trauma | - High/ complex - usually mandating transabdominal repair, fecal diversion before repair

Answer 133

- 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

Answer 134

- 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

Answer 135

- 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

Answer 136

- be conservative at first (most improve over 6 mo period of observation and local care

Answer 137

- 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

Answer 138

- Complications - Anal stenosis-high bulk diet, dilation or if not successful can try Y-V advancement flap - Local sepsis- tx local maneuvers

Answer 139

- 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

Answer 140

- Sudden onset of sharp pain initiated c passage of stool that persists for hrs and associated with BRBPR

Answer 141

- 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

Answer 142

- h/o rectal problems, abscesses, fistulas, crohns or UC, recent surgery, trauma

Answer 143

pilonidal cyst, sebaceous cyst, perihydradenitis supportiva (rarely limited to anal region, chronic pain, swelling, drainage), hemorrhoids, fissures, IBD these won’t have WBC

Answer 144

- 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)

Answer 145

- 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

Answer 146

- unexplained rectal pain and s/o infxn get a CT cuz could be supralevator or occult abscess

Answer 147

- should be done if any question of occult or complicated abscess

Answer 148

- if suspect supralevator abscess

Answer 149

- 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

Answer 150

- 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

Answer 151

- if abscess is large and or deep place Malecot drain sutured into place

Answer 152

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)

Answer 153

- 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

Answer 154

- close f/u cuz a small abscess may have been missed

Answer 155

- 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

Colon and Rectum Flashcards

(182 cards)