Colorectal II Flashcards
Low rectal cancer is usually treated with [] surgery.
How do you adapt ^ to avoid the high risk of anastomotic leak? [1]
What is the contraindication to this? [1]
Low rectal cancer is usually treated with a low anterior resection
- Contraindications to this include involvement of the sphincters
- 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
What type of stoma is this? [1]
Loop stoma
What type of stoma is this? [1]
Label which of A & B is the proximal and distal part [2]
Double barrel stoma
A: Proximal
B: Distal
State what the three different types of colostomy are [3]
Loop colostomy
End colostomy
Double barrel colostomy
Describe what a loop colostomy is [3]
Temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery
Allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function, by draining into a stoma bag
They are usually reversed around 6-8 weeks later
Describe how you differentiate between the proximal and distal end of a loop colostomy [1]
The proximal end (the productive side) is turned inside out to form a spout to protect the surrounding skin.
This distal end is flatter
Describe what a double barrel stoma is [1]
Divides the colon into 2 ends that form separate stomas:
Stool exits from one of the stomas & mucus made by the colon exits from the other
Describe what is meant by pancaking of a stoma [1]
Internal layers of the stoma bag stick together causing a vacuum which prevents the contents from dropping to the bottom. The stool remains at the top of the stoma bag which can potentially block the filter. The bag can also be forced off the body.
Physiological complications of high output ileostomy? [2]
○ > 1.5 - 2 litres
○ Fluid & Electrolyte imbalance
■ Dehydration, AKI
■ ↓Na, ↑K, ↓Mg (Addison’s picture)
■ Vitamin B12, Folate Def.}}
Problems associated with low volume ileostomy? [2]
● Low Volume (↓frequency & or quantity)
○ Stenosis
○ Impending obstruction}
Treatment for high output stomas? [5]
● Hydrate (fluid and high salt replacement)
○ Glucose-electrolyte solution aids sodium absorption
○ Restrict low sodium (Hypotonic) fluid (500-1000ml/day)
● Anti-diarrhoeal medication, eg loperamide
● Anti-secretory drugs
○ PPI (omeprazole) ○ Octreotride (rarely)
● Correct Hypomagnesaemia
● Opiates (codeine phosphate)
Where exactly are loop colostomies located? 1[]
usually in the right transverse colon, proximal to the middle colic artery
Ileostomies can be low or highoutput:
Low output tends to output [] ml/day for a low output ileostomy, and [] ml/day for a high output ileostomy
tends to output 500 ml/day for a low output ileostomy, and 1000 ml/day for a high output ileostomy
Define what is meant by a parasternal hernia [1]
Parastomal hernia is a type of incisional hernia occurring in abdominal integuments in the vicinity of a stoma, i.e. a condition wherein abdominal contents, typically the bowel or greater omentum, protrude through abdominal integuments surrounded by the hernia sac at the location of formed stoma
How do you determine if a stoma has a parasternal hernia?
Positive cough impulse and and lump at the hernia site
What are the NICE guidelines on what makes patients with colorectals adenomas low, intermediate and high risk? [3]
How often should low, intermediate and high risk colorectal adenoma patients be offered colonoscopies? [3]
Classification of risk and advised management in patients with colorectal adenomas are as follows:
Low risk
- one or two adenomas smaller than 10 mm
- should be considered for colonoscopy at five years
Intermediate risk
- three/four adenomas smaller than 10 mm
or
- one/two adenomas if one is 10 mm or larger
- should be offered a colonoscopy at three years
High risk
- five or more adenomas smaller than 10 mm
or
- three or more adenomas if one is 10 mm or larger
- offered a colonoscopy at one year.
National Institute for Health and Care Excellence (NICE) guidelines recommend a surveillance colonoscopy for patients with UC how often for low, medium and high risk patients? [3]
aLow: every 5 years
Medium: every 3 years
High: annually
What are the borders of Hesselbach’s triangle? [3]
R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border
Define what is meant by a Pantaloon hernia [1]
A pantaloon hernia, also known as a saddlebag hernia, is defined as any combination of two adjacent hernia sacs of the femoral or inguinal region (direct or indirect inguinal hernias (alternative plural: herniae)) on the same side
Thus, examples include: femoral with direct hernias, femoral with indirect hernias, indirect with direct hernias.
Difference in anatomy of femoral and inguinal hernia? [2]
Inguinal:
superomedial to the pubic tubercle
Femoral:
inferolateral to the pubic tubercle
Describe the management of uncomplicated hernia [4]
Surgery:
Open mesh repair:
- Direct hernia: plication
- Indirect: sac excision
- Both: add mesh which produces fibrosis
Laporoscopic mesh repair:
- As above, but reduced injury of nerves & post-op chronic pain
- Reinforces wall to elimiante reoccurence
Laporoscopic pre-peritoneal mesh repair
Suture repair (high chance of reoccurance
PassMed:
Primary unilateral/ bilateral hernia:
* Mesh repair(Lichtenstein’s or endoscopic repair), the mesh repair uses polypropylene mesh to reinforce the posterior wall. A recurrence rate of 2-10% for both procedures.
Recurrent inguinal hernia:
* If previous anterior hernia repair: open preperitoneal mesh or endoscopic approach
* If previous posterior hernia repair: Lichtenstein’s totally extraperitoneal (TEP). A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.
Which nerves are present in area that open and laparoscopic mesh repair occur in? [3]
The iliohypogastric nerve, ilioinguinal nerve and genital branch of the genitofemoral nerve
Laparoscopic mesh repair is particularly good for repairing what type of hernias? [1]
Bilateral hernias
What is a spigelian hernia? [2]
A Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris.
This is the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall. Usually, this occurs in the lower abdomen and may present with non-specific abdominal wall pain.
Inguinal hernias are more commonly found on which side? [1]
Why? [2]
Right sided
Due to descend of the testis or previous appendectomy
Which medical conditions might predispose a patient to an inguinal hernia? [2]
collagen defect medical conditions such as Ehlers-Danlos syndrome, Marfan’s syndrome.
Describe the method used to test for indirect inguinal hernia c.f. direct [2]
To test for indirect inguinal hernias:
- finger pressure should be applied over the deep inguinal ring. The finger pressure will control the hernia when the patient coughs.
To test for direct hernias:
- instruct the patient to cough, and a bulge should appear medial to point of finger pressure.
- If a hernia reappears it is more likely to be a direct inguinal hernia whereas if it does not, it is more likely to be an indirect inguinal hernia.
What is the surgical procedure for recurrent inguinal hernia:
- If previous anterior hernia repair? [1]
- If previous posterior hernia repair? [1]
If previous anterior hernia repair:
- open preperitoneal mesh or endoscopic approach
If previous posterior hernia repair:
- Lichtenstein’s totally extraperitoneal (TEP). A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.
If a hernia cannot be reduced it is referred to as an [] hernia - these are typically [painful / painless]
If a hernia cannot be reduced it is referred to as an incarcerated hernia - these are typically painless
Describe the medical and surgical management for hiatus hernias [2]
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias
Which type of repair is best suited for unilateral [1] and bilateral or recurrent inguinal hernias [1]?
unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically
What is the difference in indications for monopolar and bipolar diathermy? [2]
Monopolar: Major surgery
Bipolar: microsurgery
Label E & F
What type of surgeries would they be used for? [1]
E: Battle
F: Lanz
Both for open appendicectomy
Label B [1]
What is the indication for B? [1]
Rooftop scar: Liver transplant
Label A [1]
What would indicate A? [1]
Kocher scar: open cholecystectomy
How long before an operation should stop the pill? [1]
4 weeks
Post-op N&V can be treated using which three drugs? [3]
Name their side effects
Ondansetron:
- Long QT
Prochlorperazine:
- Parkinsons
Cyclizine:
HF
How much glucose [1], Na, Cl and K [1] and water should be given a day? [3]
Glucose: 50-100g per day
Na K Cl: 1mmol/kg/day
Water: 25-30ml/kg/day
Define critical limb ischaemia [3]
Critical limb ischaemia is the end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest.
- Far extreme of intermittent claudification: rest pain (often constant) due to inadequate supply of blood to a limb
- < 50 mmHg at ankle
- Gangrene & ulcers
Define acute limb ischaemia [1]
Refers to a rapid onset of ischaemia in a limb.
Typically, this is due to a thrombus blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction
Name [1] and describe the classification used for PAD [4]
Fontaine classification
Describe the surgical treament options for PAD [3]
Angioplasty:
- inserting a catheter through the arterial system under x-ray guidance
- at the site of the stenosis, a balloon is inflated to create space in the lumen. A stent is can be ( but not always) inserted to keep the artery open
Endarterectomy
- cutting the vessel open and removing the atheromatous plaque
Bypass surgery
- using a graft to bypass the blockage
- may have to remove valve in a vein
- can use prosthetic graft if needed (Goretex / PTFE)
- veins last longer that prosthetic grafts}
How do you manage acute limb ischaemia? [6]
Acute emergency!
Endovascular thrombolysis:
- inserting a catheter through the arterial system to apply thrombolysis directly into the clot
Endovascular thrombectomy:
- inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
Surgical thrombectomy
- cutting open the vessel and removing the thrombus
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
Describe the surgical procedures used to treat AAA [2]
Open AAA surgery:
- cross clamp the AA above & below aneursym
- open aneursym and remove clot
- stitch in graft
Endovascular aneurysm repair (EVAR)
- A wire is passed under fluoroscopic guidance through the aneurysm sac and a stent-graft is inserted to occlude the aneurysm from the inside
- local anaesthetic
Describe how the Standford [2] and Debakey Systems [4] are used to classifiy aortic dissections
The Stanford system:
Type A – affects the ascending aorta, before the brachiocephalic artery
Type B – affects the descending aorta, after the left subclavian artery
Debakey system:
Type I – begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta
Type II – isolated to the ascending aorta
Type IIIa – begins in the descending aorta and involves only the section above the diaphragm
Type IIIb – begins in the descending aorta and involves the aorta below the diaphragm
Describe the clinical complications of varicose veins [10]
1. Swelling at ankles
2. Discomfort
3. Itching
4. Varicose eczema
6. Lipodermatosclerosis
7. Bleeding
8. Ulceration: high pressure clip off arterioles supplying oxygen to the skin in the extremities, leading to itchiness and dryness of the skin. If people itch the skin, they can break down and become an ulcer.
9. Haemosiderin: rbc red cells leaking out of insufficient veins that breaks down and Hb breaks down and becomes oxidised
10. Thrombophlebitis: inflammation of the superficial veins of the legs; constant pain that causes it to be hard, and painful
Describe the conservative [1], medical [1] and surgical [3] treatment of varicose veins
Conservative:
- Leg elevation
- Class 1/2 compression hosiery
- Weight loss
Medical:
- Topical relief for thrombophlebitis
Surgical:
- Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation
- Foam sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
- Stripping – the veins are ligated and pulled out of the leg}
How often do you AAA rescan for
3 - 4.4 cm Small aneurysm [1]
4.5 - 5.4 cm Medium aneurysm [1]
≥ 5.5cm Large aneurysm [1]
3 - 4.4 cm; Small aneurysm: Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm: Rescan every 3 months
≥ 5.5cm; Large aneurysm; Refer within 2 weeks to vascular surgery for probable intervention
Describe how you treat superifical thrombophlebitis [3]
NSAIDs
Compression socks: reduces chance of DVT
LMWH: reduces chance of DVT
You investigate a patient who is demonstrating signs of CLI.
How do you determine from the vessel affected if this patient needs open surgery or endovascular revascularization? [2]
Open surgery: lesions of common femoral artery and infrapopliteal disease
Endovascular: short segments: aortic iliac disease
Dukes Classification of colorectal cancer:
What are the 4 stages? [4]
T1 and T2 is when the tumour is still within the mucosal wall.
What is the surgical plan for treating symptomatic
- Direct inguinal hernia
- Strangulated hernia
Direct inguinal hernia:
- Open mesh repair
Strangulated hernia:
- Open non-mesh repair
NB: asymompatic hernia tx: watchful waiting & 6 month follow up
What is the conservative treatment for haemorroids [2]
Stool softeners
Topical diltiazem
Sphincterotomy
Botulinum toxin,
Insert seton
Incision and drainage
Stool softeners
Topical diltiazem
Sphincterotomy
Botulinum toxin,
Insert seton
Incision and drainage
how would you treat haemorrhoids if there are more marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is largely internal? [1]
stapled haemorroidopexy
- excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply
- At the same time the excisional component of the procedure means that the haemorroids are less prone to prolapse
Name and describe the treatment for Large haemorroids with a substantial external component? [1]
Large haemorroids with a substantial external component may be best managed with a Milligan Morgan style conventional haemorroidectomy.
- three haemorroidal cushions are excised, together with their vascular pedicle.
Which drug is often prescribed post Milligan Morgan style conventional haemorroidectomy to reduce pain? [1]
metronidazole
What is the treatment for large, external haemorrhoids?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the treatment for large, external haemorrhoids?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the definitive treatment for fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the definitive treatment for fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the usual first line therapy for fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the usual first line therapy for fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the usual third line therapy for fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the usual third line therapy for fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the usual second line therapy for haemorrhoids?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
What is the usual second line therapy for haemorrhoids?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
Treatment failures which fail topical therapy will usually go on to have what treatment fpr fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
Treatment failures which fail topical therapy will usually go on to have what treatment fpr fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy
