Colon

Question 1

ERAS

Answer 1

Enhanced Recovery After Surgery

Question 2

ERAS Preop

Answer 2

Prehabilitation
Educate about ostomy- planning and marking, dehydration
Mechanical bowel preparation with antibiotics

Question 3

ERAS periop

Answer 3

Change gowns, gloves and instruments before fascial closure
Preop chlorhexidine shower
Antibiotics 1 hour before incision
Euglycemia
Normothermia

Question 4

ERAS Postop

Answer 4

Opioid sparing- Opioids delay bowel movements- Alvimopan
Avoid drains
Early feeds, mobilisation
Wean off catheters, i v fluids

Question 5

Diverticular Disease

Answer 5

Diverticulum- Outpouching of wall of bowel into the lumen
False- Does not involve all layers of the bowel wall
True- Involves all layers of the bowel wall- Rare, usually congenital
Diverticulosis- More than diverticulum

Occurs mostly at the mesenteric border
Occurs at the point where vasa recta enters the muscular layer- weak point.

M/c at the sigmoid colon, desc colon
Rarely occurs at the rectum

Question 6

Diverticulitis

Answer 6

Mostly due to low fibre diet, constipation

Obstruction at the orifice of the diverticulum- stasis- bacterial overgrowth- inflammation- ischemia, necrosis- perforation.

<5% of the patients with diverticulosis will develop diverticulitis.

Pain abdomen (LLQ), fever, change in bowel habits.
Bleeding pr
Palpable tender mass- if phlegmon+

Question 7

Diverticulitis- CT findings

Answer 7

CT- colonic wall thickening, pericolic fat stranding

Modified Hinchey Classification:
Stage 0- Mild
Stage 1a- pericolic inflammation
Stage 1b- pericolic abscess
Stage 2- pelvic/ intraabdominal abscess
Stage 3- peritonitis
Stage 4- Fecal peritonitis

Question 8

Diverticulitis- Complications

Answer 8

Abscess
Fistula
Obstruction
Perforation

Question 9

Diverticulitis- Complications Detail

Answer 9

Abscess- Small abscess- Antibiotics. Large abscess- Needs percut drainage.

Fistula- Abscess decompresses into another organ after forming a fistula which is an abnormal connection between 2 epithelial lined organs.
Pneumaturia, fecaluria, air p.v, vaginal discharge, enterocutaneous fistula in patients S/P percut drainage of abscess.
Vesico-colic fistula- Bladder catheterised for 7-10 days- helps the bladder heal- cystogram done after 7-10days to check if the bladder has healed- if yes then decath and repair the fistula

Obstruction- Recurrent/ chronic diverticulitis- fibrosis- obstruction.
Partial obstruction- NG tube decompression, iv fluids, NPO. If obstruction resolves- plan elective resection.
If obstruction does not resolve- emergency surgery

Perforation-
1. Stage 3 Hinchey- lap lavage- place drain. Resection anastomosis with diverting ileostomy
2. Stage 4 Hinchey- Hartmann

Question 10

Uncomplicated diverticulitis

Question 11

Diverticulitis- Special populations

Answer 11

Right sided diverticulitis- Asian, young

Immunocompromised- threshold

Young patients

Question 12

Colorectal Cancer