Colorectal Surgery Flashcards
Follow up scans for colorectal cancer
Normally 6 then 18minths with 6 monthly CEA levels for 3 years
Following chemo - 6month scan occurs at end of chemo
Following liver resection - 6 monthly for 2 yrs
Scoring system is for polyps
Haggis level determines the level of invasion within the polyp
Kikuchi level determine the degree of sun mucosal invasion in the colonic wall
Paris type - morphology of the polyp
Kudo groups - pit pattern
What is the most comman extracolonic manifestation of FAP
Adenoma toys duodenal polyps
Treatment of Anal SCC
Radial chemoradiotherapy
AIN 3 - risk of progression to invasive and 6 months follow ups required
AIN 1-2. Discharge
Is reoccurrence consider APER
Endoscopic changes in UC -early
Loss of the mucosal vascular pattern occurs as a result of mucosal oedema which obscures the underlying vessels. More advanced changes include; erythema, contact bleeding, ulceration and pseudopolyps
What percentage of FAP is not inherited
25%
Radiotherapy for rectal cancer
Rectal cancer if <15cm from distal margin to sphincters
Short course radio should be followed 4-8wrrks by surgery (chemo can extend time) - Stockholm 3 trial
For bulky nodes in mesotectum or the threatened CRM
Low pressure anal fissure
Medical tx
Advancement flaps
Uc vs campylobacter infection
The histological changes seen in both UC and Campylobacter infection are identical and therefore stool testing for this should be conducted in all cases of suspected UC
Pouchitits
Establish diagnosis with endoscopy and symptoms
Initial tx is metronidazole for 2/52 or cipro
If relapses quickly or 3 relapses in a year consider long term cipro or VSL 3 (probiotic)
5 yr survival rate for salvage APER for anal SCC
40%
Up to 75% for non salvage patients (respond to chemo rad)
Amount of serosa that can have mesentry removed on ilesotomy
5cm before risk of necrosis
Anal fissure
Medical treatment has not been shown to be superior to surgery (lateral internal sphincterotomy)
Sensitivity for Ct colonoscopy
93% sensitive and 97% specific
Types of fistula in abo
Intersphincteric (70%)
Trans-sphincteric (25%)
Suprasphincteric (4%)
Extrasphincteric (1%)
CMV histology
Intra cytoplasmic inclusions
Hematoxylin and eosin stains may reveal classic findings, which include giant cells with cytomegaly and large ovoid or pleomorphic nuclei containing basophilic inclusions (owl’s eyes, halo rim).
Histology in UC
Alteration of crypt architecture. Branching crypts with marked deviation of the crypt axis from the perpendicular; variation in crypt size and/or shape; shortened crypts, with bases of crypts elevated off the muscularis mucosae
Dense neutrophilic infiltrates and neutrophils in crypts (crypt abscesses)
Ulceration may be identified, although fissuring is often absent
Histology in Crohn’s disease
Areas of chronic inflammation, comprising increased lamina propria plasma cells and lymphocytes, in association with chronic architectural distortion with patchy, mild to severe, neutrophilic inflammation, including neutrophilic cryptitis, crypt abscesses, or erosions/ulcers
Skip lesions
Granulomas
Sub mucosal fibrosis
Fissuring
Radiation enteritis
Disordered crypts
Endarteritis obliterans
Fibrosis of the lamina propria
Ulceration and fistulation
Infective colitis
Increased cellularity in the lamina propria
Neutrophilic infiltrates
Loss of crypts
Collagenous collitis
Normal crypts with lymphocytic infiltrates and collagen deposition in the lamina propria
Solitary rectal ulcer histology
Fibromuscular obliteration
Surface ulceration
Little inflammatory activity
Earliest complication of ilesotmy
Necrosis
Fistula in a 6month year old
Low fistulae in ano are not uncommon in the first year of life. There is seldom any significant associated pathology, especially if the child is otherwise well. They seldom involve the sphincter and are best laid open, which children seem to tolerate well. Detailed imaging (which in this age group requires anaesthesia) is not appropriate at this stage.
Bowel cancer screening
FIT based screening is every 2 years. In studies comparting annual with 2 yearly screening, there was no mortality difference between the groups.
Genetic cancers with eye signs
Congenital hypertrophy of the retinal pigment epithelium is strongly associated with FAP. As such, a colonoscopy is the usual investigation of choice.
Improve
Comman complication after staples haemorroidectony
Urgency is the commonest side effect of stapled haemorroidectomy
Haemorrhoids - high fibre diet
Suitable for minor haemorrhoidal symptoms and disease
Low risk
Rubber band ligation
Bands are applied to the base of the haemorrhoidal cushion above the dentate line
Mucosal necrosis and subsequent fibrosis will tend to result in elevation of the haemorroids to their normal locatio
Only likely to succeed if the underlying cause is addressed
Injection sclerotherapy
Injection of 5% phenol in almond oil at the base of the haemorroid
Deep or ineffective injection may result in pelvic sepsis or prostatitis
Milligan - Morgan haemorrhoidectomy
Involves excision of the haemorrhoidal tissue
Good for large volume prolapsed haemorrhoids
Excessive tissue excision may result in anal stenosis
Pain may be reduced by post operative oral metronidazole
Stapled haemorrhoidopexy
Use of circular stapler to excise the haemorrhoidal base and surrounding mucosa
Will elevate the cushions into the anorectum and reduce symptoms
Urgency occurs in up to 20% (though usually resolves in the first 6 months)
Large skin tags may be less effectively addressed with this technique
Urgency is a comman side effect
Doppler guided haemorrhoidal artery ligation
Uses doppler device to identify the haemorrhoidal vessel that is then underrun
Additional sutures placed to hitch up the haemorrhoidal complex
Low morbidity technique. However, equipment is expensive
Infective vs IBD
Oak. Early in Hx is more likely to be infective
FAP
More than 100 adenomatous polyps affecting the colon and rectum. Duodenal and fundic glandular polyps
APC (over 90%)
Gardner syndrome
As FAP but with desmoid tumours and mandibular osteomas
APC
Turcots syndrome
Polyposis and colonic tumours and CNS tumours
APC +MLH1 and PMS2
HNPCC
Colorectal cancer without extensive polyposis. Endometrial cancer, renal and CNS
MSH2, MLH1, PMS2 and GTBP
Mnemonic 3-2-1 for HNPCC.
3 individuals, 2 generations and one must be younger than 50 yrs.
Peutz-Jeghers syndrome
Hamartomatous polyps in GI tract and increased risk of GI malignancy
LKB1 andSTK11 (in up to 70%
Cowden disease
Also known as multiple hamartoma syndrome. Rare autosomal dominant condition with incidence of 1 in 200,000.. It is characterised by multiple mucocutaneous lesions, trichilemmomas, oral papillomas and acral keratosis. Most often diagnosed in third decade of life. Breast carcinoma may occur in up to 50% of patients and conditions such as fibrocystic disease of the breast may occur in 75% of women. Thyroid disease occurs in 75% and may include malignancy. Endoscopic screening will identify disease in up to 85% although the small bowel is rarely involved. There is a 15-20% risk of developing colorectal cancer and regular colonoscopic screening from age 45 is recommended.
PTEN (85%)
MYH associated polyposis
Autosomal recessive, multiple adenomatous polyps in GI tract, those in colon having somatic KRAS mutations
MYH
What is the commonest extra intestinal manifestation of ulcerative colitis
Activity related polyarthropathy is seen in up to 20% of patients with ulcerative colitis
Optimal length of end ileostomy
2.5cm
