Colon

Question 1

Indications for surgery in ulcerative colitis?

Answer 1

Intractibility, ANY dysplasia/carcinoma, massive colonic bleeding, toxic megacolon, acute fulminant (15%), obstruction
long standing dz > 10 years as ppx against cancer (controversial)

Question 2

Indications for surgery in Crohn’s?

Answer 2

Intractibility, intestinal obstruction, intra-ab abscess, fistulas, fulminant colitis, massive colonic bleeding, toxic megacolon, cancer, growth retardation.

Question 3

Toxic colitis

Answer 3

> 6 bloody stools/d, fever, increased HR, drop in Hgb, leukocytosis

Question 4

Toxic megacolon

Answer 4

toxic colitis + abdominal distension, pain, and tenderness

Question 5

How do you treat toxic colitis and megacolon?

Answer 5

Start with NGT, fluids, steroids, bowel rest. Abx (cipro flagyl).
50% will need surgery.

Do NOT give enemas, anti-diarrhea, anti-cholinergic, narcotics

Question 6

When do you need to take toxic megacolon or colitis for surgery

Answer 6

Pneumoperitoneum, diffuse peritonitis, localized peritonitis with increasing ab pain +/- colonic distension > 10cm, uncontrolled sepsis, major hemorrhage.

Question 7

Which extraintestinal manifestations improve after colectomy in UC?

Answer 7

Ocular problems, arthritis, anemia

Do NOT get better: PSC, ankylosing spondylitis

Question 8

Pre-op work-up (imaging) for rectal cancer?

Answer 8

Need a colonoscopy to exclude synchronous lesions

FS or rigid proctosigmoidoscope to determine precise tumor location

Depth of penetration can be assessed with rectal exam

Question 9

Tumors in distal 3-5 cm of rectum- tx?

Answer 9

T1 (submucosa only)- transanal excision, 8% incidence of mets
If invading muscle have 20% local recurrence rate

T2N0: APR or LAR has 95% 5 year survival.
You could consider full thickness local excision with chemoradiation if small T2N0.

Question 10

Who can get local excision for rectal cancer?

Answer 10

mobile tumors, <3cm, <30% of wall circumference, in distal rectum.
Well or mod differentiated.
NO vasc or lymph invasion.

Question 11

Indication for APR?

Answer 11

tumor involves sphincters or too close to do clear margins

Or if body habitus unfavorable. Or poor preop sphincter control.

Question 12

LAR definition

Answer 12

Resection of rectum below the peritoneal reflection
Must have at least 2cm margins!!

often include sigmoidectomy (if IMA transected poor blood supply for anastamosis, often has diverticulosis)

Mesorectum excision if lower half of rectum.

Question 13

Low rectal carcinoid treatment

Answer 13

2cm is cutoff.

• <2cm Wide local excision with neg margins
• > 2cm (or musc propria invasion) APR

Question 14

High rectal carcinoid

Answer 14

1 cm is cutoff.
<1cm: polypectomy
>1cm formal resection

Question 15

T definition for colorectal

Answer 15

T1 into submucosa
T2 into muscularis propria
T3 through muscularis propria or into subserosa
T4 through serosa into free peritoneal cavity

Question 16

Treatment of rectal cancer?

Answer 16

T1 (low rectal): excise locally if <4cm, neg margins (2mm), well diff, no lymph/neuro invasion.

Low rectal T2: APR or LAR

Stage II and III: preop chemo-XRT

Stage IV: chemo and XRT +/- surgery

Question 17

Chemo used in colorectal cancer?

Answer 17

FOLFOX: 5-FU, leucovorin, oxaliplatin

Question 18

Recurrence rates of colorectal?

Answer 18

20% in first year

5% will get another primary (this is why you do colonoscopy after 1 year)

Question 19

APR risks?

Answer 19

Injury to pudendal nerve > impotence and bladder dysfunction

Question 20

Staging of colorectal

Answer 20

Stage 0: Tis, N0, M0
Stage I: T1-2 (up into musc propria)
Stage IIa and IIb: T3 and T4
Stage IIIa and IIIb and IIIc: T1-2 + N1, T3-4 + N1, Any T + N2

Stage IV: any T, any N, ANY M

note: n1 is 1-3 nodes, N2 >4 nodes, N3 central nodes pos.