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ORAL BOARDS > COLORECTAL + ANAL > Flashcards

COLORECTAL + ANAL Flashcards

1
Q

Left hemicolectomy - oncologic resection involves ligation of which vessels

A

Left colic vessels

If at splenic flexure, left branch of middle colics

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2
Q

Li fraumeni gene

A

p53

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3
Q

Lynch gene

A

MSH2
MLH1*
MSH6
PMS2

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4
Q

If MLH1 is positive, what other test?

A

BRAF needs to be NEGATIVE in order to be Lynch

If positive - somatic mutation, NOT lynch!

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5
Q

Lynch syndrome- high risk of what cancers

A 
Colon
Endometrial (esp MSH6) - can offer prophylactic TAH/BSO
Stomach
HPB
SB
Urinary tract* (diff from HAP)
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6
Q

Screening Guidelines for Lynch

A

Cscope at age 20, q1-2 years
EGD at age 25 q3-5 years
Annual pelvic exam, US, and endometrial aspiration @ age 30

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7
Q

Prolapse vs hemorrhoids

A

Mucosal ring vs radial folds

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8
Q

Delorme Procedure

A

Stripping of mucosa from prolapsed bowel
Placating denuded muscular wall
Reanastomosing the mucosal rings

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9
Q

Altemeier

A

Lonestar retractor placed at dentate line
Prolapsed segment is grasped with Babcock clamps
Score circumferential incision 1-1-1.5 cm proximal to dentate and deepen through all layers of rectal wall circumferentially
Clamp distal edge of rectum
Sharp dissection to free hernia sac, then resect sac and deliver redundant bowel
Reapproximate peritoneal edges w/absorbable suture
Enseal to seal and divide mesorectum

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10
Q

Transabdominal rectopexy

A

Posterior dissection - dissect rectum out of pelvis in the total mesorectal plane until you reach levator
Pull redundancy out of pelvis
Permanent suture to peritoneum to pexy to presacral fascia

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11
Q

Colovesical fistula takedown

A

Grasp sigmoid to tent up IMA and trace down to pedicle to do high ligation
Medial to lateral dissection
Free up splenic flexure
Continue down to anterior peritoneal reflection or rectosigmoid junction and transect
Proximal resection proximal to inflammatory area
Fix bladder: can backfill with dilute methylene blue, repair in 2 layers using absorbable PDS
Leak test

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12
Q

Sigmoid mobilization techniques

A

Can ligate IMV just inferior aspect of pancreas (just above pancreatico-duodenal junction)
Mobilize along splenic flexure

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13
Q

Wild type KRAS

A

More responsive to cetuximab

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14
Q

Major AE of oxaliplatin

A

Peripheral neuropathy

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15
Q

Intersphincteric fistula - tx

A

Fistulotomy

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16
Q

Fistula that takes up majority of internal sphincter and 50% of external sphincter – tx

A

Draining seton

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17
Q

S/p seton placement - now what?

A

Endorectal mucosal advancement flap

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18
Q

Neoadjuvant chemotherapy in rectal CA

A

N+, T4, distant mets

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19
Q

Anatomic def of upper rectum

A

Anterior peritoneal reflection* divides mid and upper rectum (>10 cm)

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20
Q

Two oncologic reasons to perform APR

A

Unable to obtain distal margins of 1-2 cm

Invasion of external sphincter

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21
Q

Lateral internal sphincterotomy

A

Prone position
2 cm radial incision at intersphincteric groove in lateral position away from hemorrhoidal tissue
Dissect into groove and isolate sphincter muscle with kelley clamp for the length of the fissure
Divide internal sphincter muscle with bovie
Close skin with 3-0 chromic
Amount divided = proportionate to fissure size

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22
Q

T staging for anal SCC

A

Like breast, not colon

Based on SIZE

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23
Q

Nigro protocol

A

5 FU + mitomycin C

45 Gy

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24
Q

Single 1.5 cm adenoma - rescope ?

A

3 years

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25
Q

2 small <10 mm adenomas - rescope?

A

5 years

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26
Q

3 small <10 mm adenomas - rescope?

A

3 years

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27
Q

How many biopsies for UC/Crohns cscope

A

Minimum 33

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28
Q

Cecal diverticulitis but cecum is not inflamed and you thought it was acute appy - what do you do?

A

Still take out appendix

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29
Q

Utility of EUS in rectal cancer

A

Can help distinguish between T1 and T2 since pelvic MRI isnt as good

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30
Q

Nodular peripheral enhancement on imaging (liver)

A

Hemangioma

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31
Q

Central stellate scar on imaging (liver)

A

FNH

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32
Q

Hypervascular pattern with arterial enhancement and rapid washout (liver)

A

HCC

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33
Q

Hypervascular in arterial phase (liver)

A

hepatic adenoma

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34
Q

hypodense lesions (liver)

A

metastatic CRC

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35
Q

Early stage rectal CA - T and N stage

A

T1-2, N0

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36
Q

Locally advanced rectal CA - T and N stage

A

T3-T4, N0 or N+

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37
Q

“Favorable” early stage rectal CA

A

Full thickness excision
<3 cm, well differentiated, without LVI, within 8 cm of anal verge
Able to obtain 3 mm margins on final specimen

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38
Q

LAR - OR

A

Medial to lateral dissection of rectosigmoid colon starting at sacral promontory
Develop plane between RP and colon mesentery
Identify IMA** and isolate at takeoff from aorta
Be sure to ID left ureter** and then divide IMA
Continue medial to lateral dissection until reaching paracolic gutter
Mobilize splenic flexure by dividing all attachments to the colon and completely medialize descending colon
Begin TME dissection posteriorly and ID/protect hypogastric nn**
Fully mobilize rectum down to pelvic floor and ID point of transection 2 cm distal to tumor
Divide colon proximally and distally and perform stapled tension free EEA
Perform leak test and once negative, create diverting loop ileostomy at site marked preop by EST

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39
Q

Ureter injury below pelvic brim - how to fix?

A

Ureteral implantation into bladder

Mobilize bladder anteriorly and facilitated by psoas hitch or boari flap

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40
Q

Anal canal - NCCN definition

A

begins at anorectal rim and extends to anal verge

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41
Q

Anal verge - NCCN definition

A

intersection of squamous-mucocutaneous junction with perianal hairbearing skin

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42
Q

SCC >5 cm from anus treated as

A

regular skin cancer

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43
Q

Staging imaging for anal CA

A

CT C/A/P +/- pelvic MRI (esp bulky anterior tumors to r/o prostate or vaginal involvement)

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44
Q

Fissures - most common location

A

Anterior midline

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45
Q

anal fissure - tx options

A

Fissurectomy
Botox 40-100 units directed into sphincter or IS space
Lateral internal sphincterotomy
Dermal advancement flap

46
Q

Onset of botox in tx of fissures

A

2 weeks

47
Q

Classic intraoperative findings of chronic anal fissure

A

Tear in anal canal
External skin tag
Hypertrophy of papilla
Heaped up edges of fissure

48
Q

Hypotonic sphincter –> fissure, tx?

A

Anodermal advancement flap by performing fissurectomy with anodermal advancement flap over the base

49
Q

Hemorrhoidectomy

A

Minimizing anoderm excised
Dissect hemorrhoidal tissue off internal sphincter
Suture ligate hemorrhoidal pedicle
Close mucosal defect with 3-0 chromic suture
Leave edge of wound open for drainage

50
Q

Rubber band ligation - be sure to ID?

A

Apex of hemorrhoidal pedicle and well above dentate line

51
Q

Horseshoe abscess and fistula - modified hanley procedure

A

Skin incision @ point of maximal fullness in posterior midline
Divide anococcygeal ligament
See if can pass fistula probe from this space into internal opening to see if can pass seton
Counter incisions of maximal fullness overlying bilateral ischiorectal fossa and place setons from openings to posterior midline to keep open and allow to drain
Use tonsil clamp to break up all loculations and irrigate until effluent is clear

52
Q

Fistulotomy - OR

A

Divide skin and muscle overlying fistula tract
Tract + edges are debrided until there is healthy tissue
Hemostasis obtained
Wound left open
Alternatively marsupialization edges of tract to allow wound to heal from base

53
Q

LIFT - OR

A

Exchanging seton for fistula probe
Make inciison externally in intersphinctic groove and dissecting out fistula tract between ext and int sphincter so that all is left is fistula probe
Suture is used to tie off ext and int tracts within sphincteric groove
Hydrogen peroxide injected into ext tract to ensure fistula has been completely disrupted
Endorectal advancement flap by dissecting out mucosal flap distal to internal opening of fistula (partial thickness of int sphincter or even full thickness)
U shaped flap extended proximally so length is 2x width
Internal tract IDed and closed with suture
Mucosal flap secured 1 cm distal to internal opening

54
Q

colonoscopy prep

A

miralax split dose prep (dose day before then 3-4 hours prior to cscope) and CLD day before
NPO p MN
confirm no blood thinners or allergies
informed consent and time out

55
Q

cscope - OR basics

A

start with DRE
advance scope under direct visualization to cecum as identified by appendiceal orifice, ileocecal valve and crows foot of cecum
withdraw scope spending at least 6 min on withdrawal

56
Q

Trouble adv at splenic flexure

A 
reduce any loops in scope
abd pressure from assistant
stiffen scope
switch to pediatric scope
position pt on back
incr sedation
57
Q

Unable to make forward progress on c-scope

A

call partner

otherwise abort procedure and get same day ct colonography

58
Q

5 mm pedunculated polyp in transverse colon

A

cold snare polypectomy

59
Q

8 mm sessile polyp in descending colon

A

cold snare polypectomy

60
Q

1.5 cm pedunculated polyp in sigmoid colon

A

hot snare polypectomy and close mucosal defect with clips

61
Q

when to consider tattoo in cscope

A

adv polyp >1 cm

62
Q

Anal margin SCC vs anal canal SCC

A

If anal margin T1/T2 (<5 cm) - WLE with negative margins 1 cm

63
Q

Anal margin SCC: T3/involve sphincter/node+/recurrence

A

5-fU and cisplatin

If fails , APR

64
Q

What else should you consider (operatively) when doing APR for pt who had prior Nigro protocol

A

myocutaneous flap to help with wound healing

65
Q

APR - OR

A

lithotomy
laparotomy
mobilize distal colon and rectum
divide mesentery at proximal superior rectal a branch (off IMA), TME
Once you reach pelvic floor, start perineal dissection with wide dissection around levators
Place muscle flap in area of resected specimen
close perineum in layers

66
Q

surveillance in anal SCC

A

q3-6 mos exams for 5 years (incl. inguinal nodes)
anoscopy q6-12 mos for 3 years
T3/T4 and any N+ also need annual CT C/A/P x 3 years

67
Q

tx of mild c diff

A

PO vanco

68
Q

tx of diarrhea + any additional signs or symptoms

A

Flagyl 500 mg PO TID

69
Q

tx of c diff + either leukocytosis, hypoalbuminemia, or abd tenderness (severe c diff)

A

vanco 125 mg PO qid + IV flagyl

70
Q

tx of complicated c diff

A

flagyl 500 mg IV TID + vanco 125 mg PO qid + vanco 500 mg in 500 mL saline as enema qid (if ileus or distended)

71
Q

C diff - OR

A

Try to mark pt for ileostomy pre op
Lithotomy, proctoscopy, midline lap, colonic mobilization, transection of mesentery ( ligate ileocolic, right colic, middle colic, left colic, and sigmoid vessels), divide ileum and rectosigmoid junction, remove entire colon, bring up end-ileostomy, oversew rectal stump, irrigation, place drain in pelvis, closure of fascia and skin, mature ileostomy

72
Q

how much anal sphincter should be preserved when doing sphincterotomy

A

2.5 cm

73
Q

how to determine sphincter length

A

awake pt
palpate posterior anal canal, measure distance from levator ring at one’s fingertip to anal verge
normal length 2-5 cm

74
Q

how to create j pouch/ipaa

A

lithotomy, total proctocolectomy (divide mesentery close to bowel wall unless CA suspected), divide TI with stapler while preserving ileocolic artery, divide rectum at anorectal junction atl evel of levators with TA 30 stapler
Mobilize small bowel and mesentery (full LOA, separation of SMA pedicle from D3)
If bowel does not reach perform lengthening procedures
Make 15 cm J pouch by stapling distal 2 limbs of ileum together with GIA stapler and inserting anvil of EEA stapler and creating stapled anastomosis to anal canal
Perform diverting loop ileostomy

75
Q

How to create length to create a J pouch (alternative options)

A

divide peritoneum overlying mesentery, selective ligation of mesenteric blood vessels (transilluminate to ensure colalterals)
can ligate ileocolic a

76
Q

If crohn’s is discovered when creating a J pouch?

A

cant do a J

must do ileostomy

77
Q

ways of dealing with difficult rectal stump

A

oversew and leave red rubber in rectum
mucus fistula
bury stump in subq so if it blows, mucus fistula can develop

78
Q

surveillance of j pouch

A

yes beginning 8 years after onset of UC

79
Q

tx of pouchitis

A

abx

80
Q

most valuable tumor marker in appendiceal carcinoid

A

plasma chromogranin A, corresponds to tumor load

81
Q

Pt with appendiceal carcinoid + high chromogranin A - next step?

A

octreoscan

best test to find metastatic disease

82
Q

Appendiceal carcinoid >2 cm, incomplete resection, evidence of metastatic disease or goblet cell tumors warrant what additional testing

A 
plasma chromogranin A levels
CT scan abd/pelvis
24 hr urine 5-HIAA
octreotide scintigraphy 
Need to assess rest of GI tract with EGD/cscope and capsule endoscopy to r/o other GI tumors
83
Q

What size appendiceal carcinoid do not require staging?

A

if <1 cm unless high-grade and/or malignant

84
Q

appendiceal mucinous tumor involving base of appendix - tx?

A

cecectomy

85
Q

who gets adjuvant tx in rectal CFA

A

pT3, pT4, or any N+

86
Q

who gets neoadjuvant therapy in rectal CA

A

T3 or any N

87
Q

What is preferred total neoadjuvant therapy

A 
FOLFOX 12-16 weeks
Then long course chemo/RT with infusional 5-FU
then restaging (8 weeks after completion)
88
Q

Colon CA at splenic flexure - which vessels

A

L colic
L branches of middle colic
IMV

89
Q

Minimum LN in colon CA

A

12

90
Q

Left hemicolectomy (colon CA)

A

ex lap with transection of IMV at level of ligament of treitz
transect left colic a at level of origin from IMA
complete medial to lateral mobilization of splenic flexure of colon
transect white line of toldt
transect splenocolic, gastrocolic ligaments
stapled transection of colon with 5 cm margins
colo-colonic anastomosis

91
Q

which artery should be ligated when tumor is distal to mid-transverse colon

A

ascending branch of left colic

92
Q

obstructing transverse colon CA - OR approach

A
  • Prophylactic antibiotics and subcutaneous heparin
  • Low lithotomy
  • Midline laparotomy (examine the entire cavity looking for mets)
  • Decompressive colotomy of proximal R colon can make the procedure easier (prior to this, place a purse string suture around a suction)
  • Mobilize R colon from lateral to medial to the level of anterior D2
  • Enter lesser sac at hepatic flexure
  • Remove the greater omentum from the stomach since it is a TRANSVERSE colon cancer
  • Mobilize the splenic flexure
  • Divide the mesentery, ligating ileocolic, middle colic, and ascending branch of the L colic a (ascending branch is ligated when the tumor is distal to the mid-transverse colon)
  • Construct ileocolic anastomosis distal to splenic flexure (unless the patient is hemodynamically unstable or there is gross feculent peritonitis needing stoma) in descending colon due to concerns for watershed blood supply
  • Hand sewn end-to-end with inner layer of running absorbable 3-0 and outer 3-0 interrupted silks → to manage size discrepancy, can enlarge small bowel and “bevel” the aperture along the antimesenteric side of intestine
  • Can also do stapled side-to-side/functional end-to-end anastomosis
  • Close mesenteric defect
  • Irrigate and close the abdomen
93
Q

Extended R hemicolectomy - OR

A

Start medial–> lateral dissection and perform high ligation of ileocolic pedicle and right colic artery after clearly identifying duodenum
medial to lateral dissection of ascending colon taking care to protect kidney, ureter, duodenum, in RP plane
Incise white line of Toldt laterally and take down gastrocolic ligament to enter lesser sac
Needs dissection and division of middle colic vessels (ext right)
once completely mobilized, extracorporalize specimen and divide ileum 5 cm proximal to ileocecal valve and colon near splenic flexure
tension free stapled SSA ileocolic

94
Q

Surveillance in colon CA

A

H&P q3 months x 2 years then q6mo x 5 years
CEA q3 months x 2 years then q6mo x 5 years
CT C/A/P q6months x 5 years
Colonoscopy at 1 year

95
Q

UC - findings (endoscopic and histologic)

A

continuous inflammation, starting @ rectum

superficial lymphoid aggregates, crypt abscesses

96
Q

Crohns - findings (endoscopic and histologic)

A

skip lesions, involvement of TI, cobblestone edema, apthous and deep ulcers, strictures
granulomas, transmural inflammation

97
Q

IPAA - ileal pouch wont reach anus. Pouch lengthening maneuvers?

A

Ensure small bowel mesentery fully mobilized off RP all the way to LoT and 4th portion of duo
Perform high ligation of ileocolic pedicle
Assess diff sections of TI as best point of apex for pouch in terms of reach
IF still wont, can make relaxing incisions on both sides of SB mesentery perpendicular to vessels
If still wont, selectively divide mesenteric arcade
Create S shaped pouch or leaving defunctioning J pouch with plans to reoperate in 6 months

98
Q

Elderly man with LUQ pain and bloody BM - next steps

A

Adequate IV access
CBC, CMP, lactate
Stool studies to r/o infectious etiologies
If Cr ok, can get CT A/P

99
Q

Mild c diff definition

A

WBC < 15 AND Cr < 1.5

100
Q

Severe c diff definition

A

WBC > 15 AND/OR Cr >1.5

101
Q

Fulminant c diff colitis definition

A

Hypotension, septic shock, ileus, megacolon, or need for ICU

102
Q

Toxic colitis definition

A

Colon dilation

103
Q

Sigmoid volvulus - flex sig OR

A

Propofol sedation
Introduce scope under direct visualization through anus and rectum
Minimal insufflation of CO2 until reach area of narrowing and twisting
Gently advance until reach dilated colon proximally
Suck out as much gas and stool proximally as possible
Leave decompressive rectal tube

104
Q

Diverticulitis - OR (not super sick)

A

Midline laparotomy
Washout abdomen thoroughly
Mobilize descending colon and splenic flexure, taking care to identify ureters
ID transection margins; proximal would be distal most margin of healthy uninvolved colon and distal margin proximal rectum; then perform tension free colon to rectal EEA
Sigmoidoscope for leak test
Diverting ileostomy

105
Q

1-2 tubular adenomas found on cscope - when to repeat?

A

5-7 years

106
Q

3 tubular adenomas found on cscope - when to rescope?

A

3 years

107
Q

Single adenoma >10 mm with tubulovillous, villous or high grade dysplasia - when to rescope?

A

3 years

108
Q

If >10 adenomas found, when to rescope?

A

1 year

109
Q

Ostomy triangle

A

ASIS
umbilicus
pubic symphysis

110
Q

End Ostomy OR

A

Clamp skin with kochers and remove 3 cm disk of skin
Protect bowel by placing sponge deep to peritoneum and anteriorly on the abdominal wall
Divide through fascia with cautery and spread apart the rectus muscle
Divide posterior sheath longitudinally
Distal aspect of intestine oriented to ensure mesentery isnt twisted and a babcock is passed through trephine and intestine is brought through to the skin without tension
Place sutures full thickness from mucosa to serosa
Sutures passed through subq layer

111
Q

Loop ostomy OR

A

Sutures of differing colors can mark proximal and distal limbs
Create window in mesentery adjacent to bowel and pass umbilical tape through the opening
Grasp ends of umbilical tape through trephine and exchange tape for ostomy rod
Distal aspect opened transversely leaving posterior wall intact
Sutures full thickness through bowel and into the dermis - first distal, then proximal

ORAL BOARDS (11 decks)

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