Colorectal surgery

Question 1

what types of vitamins do the bacteria in the colon produce?

Answer 1

vitamin K and B

Question 2

What structures make up the foregut?

Answer 2

Oesophagus
Stomach 
Proximal duodenum 
liver
gall bladder
pancreas

Question 3

What structures make up the midgut?

Answer 3

Distal duodenum 
ileum
cecum
appendix 
ascending colon
proximal 2/3 of transverse colon

Question 4

What structures make up the hindgut?

Answer 4

distal 1/3 of transverse colon
descending colon
sigmoid colon
rectum 
proximal anus

Question 5

Where is the anastomoses located that connects the left and right side of the colon?

Answer 5

splenic flexure

Question 6

Define the term ‘watershed’

Answer 6

an area that receives dual blood supply from the most distal branches of two large arteries, such as the splenic flexure of the large intestine

Question 7

Which vein drains the ascending colon?

Answer 7

superior mesenteric vein then into the portal vein

Question 8

Which vein drains the descending colon?

Answer 8

inferior mesenteric vein into the splenic vein

Question 9

Colorectal cancer info

Answer 9

very common

M>F but depends on risk factors

Question 10

How are patients screened for colorectal cancer?

Answer 10

Quantitative faecal immunochemical test (qFIT) - less hassle, more sensitive to haemoglobin, more uptake from patients

Replaced Faecal occult blood test (FOBT)

Question 11

Almost every case of colorectal cancer develops from what?

Answer 11

an adenoma

hence why screening is important - want to detect adenoma at early stage

Question 12

Typical symptoms of patient with suspected colorectal cancer (7)

Answer 12

Abdominal pain - colicky (starts and stops abruptly)

Rectal bleeding – anorectal pain?, colour?, mixed in stool?

Change in bowel habits (diarrhoea, constipation)

Weight loss

Tenesmus – sensation of having something in their rectum

Fatigue

Vomiting

Question 13

High risk features that indicate diagnosis of colorectal cancer (6)

Answer 13

Persistent change in bowel habit (>6 weeks)

Persistent rectal bleeding without anal symptoms

Right sided abdominal mass (higher up the GI tract - more serious)

Palpable rectal mass

Unexplained iron deficiency anaemia – consider menopausal women?

Patients in whom there is clinical doubt

Question 14

Investigations for colorectal cancer

Answer 14

Colonoscopy +/- biopsies (gold standard)

Radiological imaging

• CT colonography
• Plain CT abdo/pelvis with contrast

Staging CT if confirmed CRC (CT chest)

Pre-op MRI in confirmed rectal cancer

Others i.e PET scan

Question 15

CT Chest abdomen pelvis (CAP) is used for what?

Answer 15

to stage colorectal cancer

Question 16

Which part of the colon does the tumour most commonly lie in?

Answer 16

Proximal 43%

Distal 30%

Question 17

True or false?

Colon and rectal cancer treated as 2 separate entity

Answer 17

true

Question 18

How does colon cancer management differ to rectal cancer

Answer 18

almost always straight to surgery if no metastatic disease and patient is fit

not straight to surgery - pre-op MRI important in rectal cancer - may need neodjuvant chemo, radiotherapy or both followed by surgery

Question 19

What is the fatty enevelope that surrounds the rectum called? and why does it need to be removed sometimes?

Answer 19

mesorectum

contains all the draining lymph nodes of the rectum

Question 20

what is a total mesorectal excision and why is it done

Answer 20

To reduce local recurrence rate as if cancer has spread to the mesorectal fascia surgery would be pointless

the rectum and it’s surrounding mesorectum has to be excised all together

almost all colorectal cancer patients will have this done

Question 21

What is the circumferential resection margin

Answer 21

Area between the tumour and peritoneum - need clear resection margin to be able to operate

If tumour has invaded the peritoneum then surgery would be pointless as would likely reoccur

Question 22

Neoadjuvant treatment + rectal cancer

Answer 22

Should give Neoadjuvent therapy first – chemo or radio or both to try and decrease tumour size and make clear resection margin

restage 6-8 weeks later after treatment

Question 23

What things do you have to consider before surgery for rectal or colon cancer?

Answer 23

Resection - removing whole tumour

Restoration intestinal continuity

Faecal diversion: Stoma

Preservation of function

Question 24

Difference between ileostomy and colostomy

Answer 24

ileostomy - usually R iliac fossa, liquid or looser stools and spouted out of the skin

Colostomy - usually in left iliac fossa, solid stools, no spout, flush with skin

Question 25

Complications of general resection surgery

Answer 25

Bleeding

Infection (superficial & deep)

Anastomotic leak

Stoma problems (ischaemia, retraction, prolapse, hernia, high output)

Question 26

Complications of low Anterior Resection (LAR) (surgery to treat rectal cancer)

Answer 26

Damage to pelvic nerves – bowel, urinary, sexual dysfunction

Possible impaired fertility in younger women

Question 27

Post-op management

Answer 27

Dependent on pathological staging

Adjuvant chemotherapy may be required

Post-operative complications might hinder or delay adjuvant treatment

Surveillance CT CAP, colonoscopy

In NHS Grampian alternate USS liver + CT CAP every 6 months

Question 28

Cardinal signs and symptoms of bowel obstruction (4)

Answer 28

Abdominal pain
Vomiting
Absolute constipation (flatus and solids)
Abdominal distension

Question 29

What serious problems can bowel obstruction cause

Answer 29

hypovolemic shock or septic shock due to fluid shifts in the body and/or excessive vomiting.

Question 30

how is septic shock caused by bowel obstruction?

Answer 30

bowel distension - venous compression - decreased oxygenation - bowel cells die - increased toxins in circulation (lactic acids and bacterial toxins)

Question 31

Benign causes of large bowel obstruction

Answer 31

Strictures (diverticular, ischaemic)

Volvulus

Faecal impaction

Intussusception

Pseudo-obstuction

Question 32

what is volvulus

Answer 32

when a loop of intestine twists around itself and the mesentery that supports it

Question 33

what is intussusception

Answer 33

one segment of intestine “telescopes” inside of another, causing an intestinal obstruction

Question 34

Causes of small bowel obstruction (2)

Answer 34

adhesions

hernias

Question 35

Immediate management of bowel obstruction

Answer 35

ABC

Fluid resuscitation

Nil By Mouth and consider nasogastric tube if vomiting

Analgesia and antiemetics

Consider IV antibiotics

Question 36

Investigations for bowel obstruction

Answer 36

Bloods (FBC, U&Es, G&S, Coagulation screen)

Blood gas (Lactate, pH, BE)

CT abdo/pelvis

Question 37

When would you not perform an anastomosis?

Answer 37

if patient has felt really unwell

if patient has no reservoir, rectal compliance, previous traumatic birth

risk of anastomotic leak