Block 2 Flashcards
Theme: Colonic resections
A.End ileostomy
B.Loop ileostomy
C.Ileo anal pouch
D.Loop colostomy
E.Pan proctocelectomy
F.Extended right hemicolectomy
G.Right hemicolectomy
H.Anterior resection
I.Anterior resection with covering loop ileostomy
Please select the most appropriate procedure from the list, each option may be used once, more than once or not at all.
A 75 year old man requires resection of an obstructing carcinoma of the splenic flexure.
A patient presenting with a large bowel obstruction from a low rectal cancer.
A 45 year old man presents with a carcinoma 10cm from the anal verge, he has completed a long course of chemoradiotherapy and has achieved downstaging with no evidence of threatened circumferential margin on MRI scanning.
Extended right hemicolectomy
Carcinoma of the splenic flexure requires extended right hemicolectomy. Or a left hemicolectomy. The ileocolic anastomosis has a lower leak rate, particularly when the bowel is obstructed.
Loop colostomy
This patient should be defunctioned, definitive surgery should wait until staging is completed. A loop ileostomy will not satisfactorily decompress an acutely obstructed colon. Low rectal cancers that are obstructed should not usually be primarily resected. The obstructed colon that would be used for anastomosis would carry a high risk of anastomotic dehisence. In addition, as this is an emergency presentation, staging may not be completed, an attempted resection may therefore compromise the circumferential resection margin, with an associated risk of local recurrence.
Anterior resection with covering loop ileostomy
Low rectal cancer is usually treated with a low anterior resection. Contraindications to this include involvement of the sphincters (unlikely here) and poor sphincter function that would lead to unsatisfactory function post resection. Most colorectal surgeons defunction resections below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. A loop ileostomy provides a safe an satisfactory method of defunctioning these patients. A contrast enema should be performed prior to stoma reversal.
Next step after diagnosis of CRC?
Completely staged using CT CAP
Entire colon should be evaluated with colonoscopy or CT colonography.
Patients whose tumours lie below the peritoneal reflection should have their mesorectum evaluated with MRI
What should be done for CRC patients with tumours below the peritoneal reflection?
Evaluation of mesorectum with MRI
What is significant about the general approach to surgical management of CRC?
Surgery is only curative option.
Lymphatic drainage of the colon follows the arterial supply, most resections are thus tailored around resection of particular lymphatic chains (e.g. ileo-colic pedicle for right sided tumours).
Following resection, a decision must be made about restoration of continuity.
What are the key technical factors in the healing of bowel anastomoses?
Adequate blood supply, mucosal apposition, no tissue tension.
Surrounding sepsis, unstable patients and inexperienced surgeons may compromise these key principles and in such circumstances it may be safer to contrsuct an end stoma rather than attempting anastomosis.
Options for CRC presenting as an obstructing lesion
Exception
Stent or resect.
In modern practice is is unusual to simply defunction a colonic tumour with a proximal loop stoma.
Exception is in the rectum
Chemotherapy following resection of CRC
5FU and oxaliplatin is common
Approach to rectal cancer surgery
Can be an anterior or APER resection.
Involvement of the sphincter complex or very low rectal tumours require APER.
In the rectum, a 2cm distal clearance margin is required and this may also impact on the procedure.
Meticulous dissection of mesorectal fat and LNs (TME) is also an integral part of the procedure.
Why can the rectum be irradiated?
It is an extraperitoneal structure- something that cannot be offered in colonic tumours
As a consequence patients may be offered neoadjuvent radiotherapy prior to resectional surgery
T1 and T2/ N0 rectal tumours
Do not require irradiation-> surgery
T4 rectal tumours
Long course chemo radiotherapy
T3 N0 rectal tumour.
Shourt course of radiotherapy prior to surgery
Management of rectal cancer causing large bowel obstruction
Will not undergo resectional surgery without staging as primary treatment (different from colonic cancer).
This is as rectal surgery is more technically demanding, the anastomotic leak rate is higher and the danger of a positive resection margin in an unstaged patient is high.
Patients with an obstructing rectal cancer should have a ?
Patients with an obstructing rectal cancer should have a?
Defunctioning loop colostomy
Right colon cancer
Type of resection
Right hemicolectomy
Transverse CRC
Type of resection
Extended right hemicolectomy
Splenic flexure CRC
Type of resection
Extended right hemicolectomy
or
Left hemicolectomy
Sigmoid CRC
Type of resection
High anterior resection
Upper rectum CRC
Type of resection
Anterior resection (TME)
Low rectum CRC
Type of resection
Anterior resection (low TME)
Anal verge CRC
Type of resection
APE of colon and rectum
Type of anastomosis
Right hemicolectomy
Ileo-colic
Type of anastomosis
Extended right hemicolectomy
Ileo-colic
Type of anastomosis
Left hemicoloectomy
Colo-colon


































