Colorectal Surgery Flashcards
Definition for Hartmans procedure
– resection of disease portion of bowl bring the proximal end out as a stoma and over sew the distal end
3 causes of small bowl obstruction
- adhesions
- HERNIA
- Neoplasm in small bowl
2 cases of large bowl obstruction
- Neoplasm
- diverticular disease
MANTELS acute appendicitis
Migration of pain Anorexia Nausea/vomiting Tenderness RLQ Rebound pain Elevation of temperature Leukocytosis Shift to the left (Neutrophiles > 75% OR LLEFT SHIFT )
Rovsing sign
palpation in LIF causes worse pain in the RIF
Psoas sign
flexion of the right hip
liw patient on left and felt hip posteriorly
Obturator sign
Pian in the right lilac fossa as a result of flexing and internally rotating the right hip
Causes of appendicitis in adults DDX
Terminal ill pathology
Crohns
Meskel’s diverticulitis
GE
Kindly stones
pancreatitis
Ovarian cyst (where in menstrual cycle) ovarian tortion
what score do you use for testing appendicitis severity
ALVARADO SCORIng SYSTEM - abdo pain which is localized in RIF - Nausea / Vomitting - Anorexia SIGNS - tenderness RIF - rebound tenderness - temperature LAB VALUES - leukocytosis > 10 000 Neutrophiles > 75% OR LLEFT SHIFT
acute appendicitis treatment
OPEN or LAP
- 15% - negative
IV antibiotics at infuctioon
Appendicitis abscess or appendicitis mass
IV ANTIBITOCIS
- may settle within 6 weeks
- if NOT – > surgery
Abscess - CT guided drainage
how to do appendectomy
gridiron incision at McBurneys Point
lap approach
find appendix
divide mesentery
clamp appendix and tied at base then excised
investigate stump using purse=string in the wall of the caecum round the base of the appendix
Complication of acute appendicitis
- perforation (localized or generalizEd )
- RIF appendix mass (appendicitis with densely adherent caecum and oentum forming a mass)
- RIF abscess
- Pelvic abscess
blood supply to the appendix
terminal branch of ileocolic
Diverticular disease
out pouching of sac like mucous projection through the colon wall
- usually in sigmoid colon
Clinical Painful diverticulosis
intermitted LID pain - constipation and diarrhea
Acute diverticulitis
LIF pain D/C Nause ± bleeding
Sign: dever, tachycardia , tender LIF ,guarding , rebound
Labs: HIGH neutrophils, elevated WCC and elevated CRP
Diverticular bleeding
Spontaneous NO prodromal symptoms
LARGE BIGHT RECTAL BLEED due to rupture of PERIDIVERTICULA SUBMUCOSAL VESSEL
complication of diverticular disease
pericolic and parabolic abscess
peritonitis
Diverticular FISTULA
STRICTURE FORMATION
pericolic and parabolic abscess presenting symptoms and treatment
SPIKING and swinging fever and sepsis
(LIF pain, N V , WL , NS )
(from persistent colonic inflammation leading to pericolic abscess)
Tx:
- Antibiotics
- percutaneous radiologically guided draining w/ washout ± research of disease bowl
difference b/w purulent peritonitis and faeculent peritonitis
Purulent - perforation of parabolic and pericolic abscess
Faeculent - free perforations of diverticular segment
question to ask in diverticular history to outule fistula
recurrent UTI
pneumaturia
debris in the urine
gold standard test for Diverticular disease
BARIUM ENEMA
COLONSCOPY
- not used in acute setting can PERFORATE the appendix
treatment of acute diverticulitis
IV antibiotics (co-amoxiclav)
Bowl rest IV fluids
Radiology guided drainage if abscess present
Hartmans
when do you do surgery for acute diverticulitis
- free perforation
- fistula
- acute inflammation unresponsive to medical treatment
- undrainable abscess
HINCHY SCORE
Hinchey I - localised abscess (para-colonic)
Hinchey II - pelvic abscess
Hinchey III - purulent peritonitis (the presence of pus in the abdominal cavity)
Hinchey IV - feculent peritonitis.
Treatment of acute diverticulitis
Hinchey I: conservative (high fibers, stool softeners)
Hinchey II: CT guided drainage and wash
Hinchey III: usually operation (Hartmans)
Hinchey IV: always operation(Hartmans)
Diverticular disease: definition
symptomatic diverticulae
Diverticulitis: definition
inflammation & infection associated with diverticula
Hold old for colorectal cancer
55-75 years MEN increase 3X
RF for Colorectal cancer
- polyposis syndrome (FAP , HNPCC, juvenile polyposis )
- strong history of colorectal carcinoma
- UC and Choirs
- deit poor in fruit and vegetables
- diet risk in red meat processes met and animal fat
- obesity
MOST ARISE FROM PRE EXCITING ADENOMA
how does colorectal cancer metastasize
lymphatics
hematogenous - liver
how can Colorectal cancer occur
Polypoid
ulceration
stenosing
infiltrative tumour mass
location of Colorectal cancer
RECTUM ( 30%)
Descending and sigmoid - 45%
transverse - 5%
Right sided 20%
definition of tenesmus
difficult painful defecation and sensation of incomplete evacuation
- THINK SOL
how does Right sided colorectal cancer present
iron deficiency anemia
Descending / sigmoid colorectal cancer presents as
PR bleed and Change in bowl habit
Dx CR cancer
ELECTIVE: PR exam signmoidscopy and BX Colonoscopy and BX CT colonagiography if colonoscopy not possible
EMERGENCY - CT
how to stage CR cancer
- LOCAL
- CT - colon cancer
- pelvic MRI and transrectal US - rectal CA - METS
- CT TAP - GOLD STANDARD
- Pet - SYNCHRONOUS TUMOUR - colonoscopy and Barium enedma
- CEA - tumor marker
- PATHOLOGY - DUKES classification , TNM
Management - potential curative treatment with NO mets evidence
OPERATIVE
Right / traverse - right / extended right hemicolectomy
LEFT colon - left hemicolectomy
Sigmoid /upper - high anterior resection
lower rectum - LOW anterior resection / APR
Anorectal - APR
general treatment of CR cancer
- OPERATIVE
- RTX (NEOADJUVANT) - reduces local recurrence
- ADJUVANT CHEMO - tumour with positive LN or evidence of vascular invasion
- HEPATIC or LUNG resection - in its with retractable mets and resectable primary tumour
- PALLITIVE
Palliative treatment in CR cancer
for unrescetbale
- CTX
- ENDOLUMINAL stents with self expanding metal steps for obstruction colon tumours
- transanal ablation of rectal obstruction tumours
- surgery for untreatable obstruction / bleeding / severe symptoms
follow up post CR Cancer treatment
1/ Outpatient review - Hx and exam , PR and CEA
2/ Colonoscopy
3/ CT scan
Internal sphicheter type of cell
Circular, non striated involuntary autonomic nerve
external sphicheter
started , voluntary supplied by pudenal nerve
lymph drainage to lower part of anal canal
injunial LN
what cells line lower part of anal canal
squamous cell
treatment of haemorrhoids
- normalize bowel and defamatory habits
- injection sclerotherapy (1st and second)
- rubber band ligation (second degree haemorrhoids )
- Transanal heamorrhoidal dearterilisation (2nd and third)
indication for a heamoroidectomy
- 3rd and 4th degree haemorrhoid
- 2nd degree that is not cured with non operative approach
- fibroses haemorrhoid
- intern-external haemorrhoid when the external haemorrhoid is well defined
types of heamorroidectomy
OPEN - milligan morgan
Closed - ferguson
Stapled
thrombosed external haemorrhoid presentation and treatment
EXCRUTIATING PAIN
Sx treatment of haemorrhoid and overlying skin - immediate relief
anal fissure definition
longitudinal split in the anoderm of the distal anal cancel which extends from the anal verge proximately towards but not belong the dentate line
Chronic fissure
> 6 weeks and presents with
- firbsosi
- fibrotic edge
- perianal skin tag
Conservative Treatment of fissure
Conservation
- warm sits baths
- constipation relief
- analgesia
- tx underlying condition
- TOPICAL NITRIC OXIDE DONORS - by decreasing spasm , pain is relieved and increased vascular perfusion and promotes healing (0.2% NO and 2% diltiazam )
Operation for fissure
lords anal stretch (historical interest only) - high risk of incontinence
Lateral SPINCTEROTOMY ( GOLD STANDARD)
- closed
- open
define anorectal abscess
acute phase manifestation of a collection of purulent material that originates from an infection arising in the cyrptoglandular epithelium lining the anal canal at the dentate line
Investigation anorectal abscess
Pelvic CT or MRI
Tx anorectal abscess
primarily surgical - anesthesia , sigmoidoscopy and proctoscopy with adequate draining of pus
presentation of anorectal abscess
Severe perianal and rectal pain, constitutional symptoms - fever , malaise
PURULENT DISCHARGE - if abscess spontaneously drained
Anal fistula definition
Chronic abnormal connection b/w 2 epithelial lined surfaces
- usually lined with granulation tissue
exam of fistula
- perianal skin may be excoriated and inflamed
- external open visual or palpated as undulation just below the skin
- hands into fistula to determine the internal opening using rotoscope or sigmoidoscope
types of anal fistula (Parks classification )
- Intersphincteric
- trans-sphincteric
- suprasphincteric
- extrasphincteric primary tracts
Parks classification note
Low or high depending on weather the internal opening is above or below the puborectalis
Goodshall’s rule
all fistula tract with external openings within 3 cm of the anal verge and posterior to a line drawn through the ischial spines travel in a curvilinear fusion to the posterior midline. All tracks with external openings anterior to this line enter the canal in a radial fashion
how to you make a definite of a fistula
Examination under anesthesia - to determine internal and external openings
Treatment fistula
- FISTULOTOMY - if the fistula lies below the puborectalis
- FISTULECTOMY - either loose tight or chemical - used for low anorectal fistulas
- SETON INSERTION - high anorectal fistulas
- ADVANCED FLAP
- PLUGS AND GLUES
SENTON INSERTION
this is done loose right or chemical - used for HIGH
- staged fistulotomy by placing a seton suture that is sporadically tightened so to gently cut through the tract and muscle while allowing healin and fibrosis to develop between diced muscles thus preserving function and fecal continence
pionidial sinus
pilus - means hair
sinus - means blind ending tract - usually lined with granulation tissue
infection of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttock
pathogenesis pionidial sinus
- loose hair gathers toward natal cleft
- draws hair deeper into the pore - suction of buttock movement
- friction causes hair to form a sinus
Pore becomes infected - abscess
treatment of pilonidal sinus
skin hygiene
acute: incision and drainage of pilonidal abscess
Chronic - phenol injection every 4-6 weeks till wound is healed
techniques for pilonidal sinus surgery
- excise sinus tract
BASCOM’s operation - lateral to midline incision to cruette the deep cavity and excision of the primary midline pits
Primary closure of the midline incision and lateral wound left to heal by secondary intention - Karydakis procedure - smilateral D shaped incision incubating the sinus down to the pre sacral facia - the flap of tissue on the vertical young side is mobilized and brought to the convex would wedge and sutured in the layers over a drain
treatment for recurrent pilonidal sinus
ROTATIONAL FLAB PROCEDURE - pasty, modified , limber flap
anal cancer RF
female infection with HPV 16 and 18 lifetime number of sexual partners genital warts cigarette smoke receptive anal intercourse infection with HIV
AIN
precursor for invasive squamous anal carcinoma
Bowen’s disease
high proportion of AIN III progresses to carcinoma
anal cancer above the dentate line drains to
perirectal and paravertebral nodes
anal cancer below the dentate line drains to
superficial injunial and femoral nodes
investigation of anal canal
- under anesthesia - Bx
- CT
- MRI
- endoanal ultrasound
Treatment of anal cancer
MDT
- wide surgical excision (T1No)
CHEMORADIO - T2 T 3 T4
APR - in advanced disease of anus and rectal tumour
why do you get that colour of melon in upper GI bleed
b/c the blood becomes altered from gastric and upper GI enzymes
isolated streaks of blood
issues in uno
differential dx for mucous in stool
Rectal Ca UC Chrons of the rectum adenoma Colitis - other cause
investigation of rectal bleed
- FBC - hb and platlets
- U/E - disproportionately raised urea due to increase creatinine in Upper GI bleed
- call
LFT
PDA - obstruction / Toxic megacolon
Colonoscopy . barium enema, proctoscope / sigmodscope
OGD
Mesternic angiography or technetium scan
what can a small bowel enema show in chons
Stricture
Prestonitic dilation
Kantor string sign
luminal narrowing revealed on x-ray as a thin line of barium terminating at the ileocecal junction.
Area which is narrowed and irregular
what can CT scan show in churns
FATD
Fistulae
Inter-abdominal abscess
bowl thickening
Dilatation
MRI USE IN chorns
to detect perianal involvement
MR enteroclysis IN chorns
small bowel structuring in young children
Fistulography
Helps demonstrate enterocutaneous fistulae with more complexity and allow adequate panning of surgery
Surgery for chrons
- ileocecal resection
- segmental resection
- colectomy and ileocecal anastomosis
- subtotal colectomy and ileostomy
- strictuotomy
what do you see on X-ray of UC
lead pipe colon thumb printing (mucosal edema)
how does pancolittis present in uC
may have backwash ileitis - SYSTEMICALLY unwell
HYPOkalemia from mucous production
Hypoalbuminemia from systemic response and decreased oral intake
Anemia from blood loss and inflammatory response
Toxic megacolon present
MASSIVELY dilated and patchy necrosis
Systemically ill with high fever marked tacky and dehydration
Culminates in perforation and detail peritonitis unless emergency colectomy is done
CT in UC
thickened bowl wall and inflammation stranding in the colonic mesentery
Surgery for UC
Subtotal colectomy with ileostomy
Panprotocolectomy with permenanat ileostomy
Restorative protocolectomy (ileoanal pouch and parks pouch )
