Colorectal Surgery

Question 1

What is the most common type of anal cancer and from where does it arise

Answer 1

Squamous cell carcinoma

They arise inferior to the dentate line

Question 2

What is the biggest risk factor for anal cancer?

Answer 2

HPV 16

Question 3

What are the first line and second line treatments to anal cancer?

Answer 3

First line: chemoradiotherapy

Second line: salvage radical abdominoperineal excision of the anus and rectum

Question 4

Diseases associated with anal fissures?

Answer 4

Crohns disease
TB
Internal rectal prolapse

Question 5

Treatment options for anal fissures?

Answer 5

Diltiazem paste or topical GTN

Question 6

How would you define a simple uncomplicated fistulae?

Answer 6

They are low down and do not involve more than 30% of the external anal sphincter

Question 7

How would you define a complicated fistula?

Answer 7

They involve the sphincter, they have multiple branches or they are not cryptoglandular in origin

Question 8

What are the best investigations for ano-rectal fistulas?

Answer 8

-endoanal US with instillation of hydrogen peroxide
-MRI rectum is very sensitive and can show you the tracking of the fistula

Question 9

What is the management options for ano-rectal fissures?

Answer 9

• seton sutures
• fistulotomy
• anal fistula plugs and fibrin glue
• anorectal advancement flaps
• ligation of intersphincteric tract procedures
• fistulotomy at the time of abscess drainage

Question 10

What are the different types of seton sutures?

Answer 10

simple setons: lie within the fistula tract to encourage both drainage and fibrosis

cutting seton: seton is inserted and the skin is incised to form scar tissue around the seton

Question 11

Most common position of haemorrhoids?

Answer 11

3, 7 and 11 o clock position

Question 12

What are some common causes of proctitis?

Answer 12

Crohns disease, UC and Clostridium difficile

Question 13

What are the different positions of anorectal abscess?

Answer 13

perianal
ischiorectal
pelvirectal
intersphincteric

Question 14

Most common cause of anal fistula?

Answer 14

Likely due to anorectal abscess

Question 15

Most common cause of a solitary rectal ulcer?

Answer 15

Associated with chronic straining and constipation

Question 16

What are the treatments for anorectal prolapse?

Answer 16

• covering with sugar in the acute setting may reduce swelling
• Delormes procedure for external prolapse - but high recurrence rate
• Altmeirs procedure: resects the colon via the perineal route, lower recurrence rates but higher risks of anastomotic leak
• Rectopexy

Question 17

What are the symptoms of appendicitis?

Answer 17

pyrexia
vomiting once or twice, but persistent vomiting would be unusual
periumbilical pain that migrates to the right iliac fossa
anorexia is very common
diarrhoea is rare

Question 18

What are the indications in appendicitis to operate?

Answer 18

Raised inflammatory markers accompanied with a fitting clinical history

Question 19

What is the follow up protocol for colorectal cancer?

Answer 19

A colonoscopy 12 months post resection

Question 20

Large non pedunculated colorectal polyps follow up?

Answer 20

R0 = One off scope at 3 years
R1 = Site check at 2-6 months with a further scope at 12 months

Question 21

What is the follow up for high risk findings on initial colonoscopy?

Answer 21

A further colonoscopy arranged in 3 years (one off)

Question 22

What would be defined as high risk findings in colonoscopy?

Answer 22

More than 2 premalignant polyps including 1 or more advanced colorectal polyps or more than 5 premalignant polyps

Question 23

What are the criteria where segmental resection or complete colectomy can be considered?

Answer 23

Incomplete excision of a malignant polyp
Malignant sessile polyp
Malignant pedunculated polyp with submucosal invasion
polyps with poorly differentiated carcinoma
familial polyposis coli

Question 24

What radiological evaluation should be taken in patients diagnosed with a colorectal cancer?

Answer 24

• CT CAP for staging
• Entire colon evaluation with colonoscopy or CT colonography
• Tumours below the peritoneal reflection should be evaluated via mesorectum MRI

Question 25

What is the surgical management for a sigmoid colon cancer?

Answer 25

A high anterior resection, anastomosing the colon to the rectum

Question 26

What is the surgical management for a high rectal cancer?

Answer 26

Anterior resection (TME) with colorectal anastomosis

Question 27

What is the surgical management for a low rectal cancer?

Answer 27

Anterior resection (low TME) with either anastomosis to the rectum or with a defunctioning stoma

Question 28

What are the macroscopic changes of the bowel in Crohns disease?

Answer 28

Cobblestone appearance with apthous ulceration

Question 29

What is the depth of disease in Crohns vs UC?

Answer 29

Transmural inflammation in crohns disease vs superficial inflammation in ulcerative colitis

Question 30

What are the histological features of Crohns disease?

Answer 30

Non caseating granulomas with langhans giant cells

Question 31

What are the histological features of UC?

Answer 31

Crypt abscesses, inflammatory cells in the lamina propria

Question 32

Where is the most water absorbed in the bowel?

Answer 32

The jejenum and ileum.