Colorectal Surgery Flashcards
1
Q
All different types of stomas:
A
- gastrostomy
- loop jejunostomy
- percutaneous jejunostomy
- loop ileostomy
- end ileostomy
- end colostomy
- caecostomy
- mucous fistula
2
Q
Use of gastrostomy:
A
- gastric decompression or fixation
- feeding
3
Q
Common site of gastrostomy:
A
epigastrium
4
Q
Use of loop jejunostomy:
A
- not used much as very high output
- following emergency laparotomy with planned early closure
5
Q
Common site of loop jejunostomy:
A
any location according to need
6
Q
Use of percutaneous jejunostomy:
A
for feeding purposes and site in proximal bowel
7
Q
Location of percutaneous jejunostomy:
A
left upper quadrant
8
Q
Use of loop ileostomy:
A
- defunctioning colon e.g. following rectal cancer surgery
- does not decompress colon (if ileocaecal valve competent)
9
Q
Location of loop ileostomy:
A
right iliac fossa
10
Q
Use of end ileostomy:
A
- usually after complete excision of colon or where ileocolic anastomosis not planned
- to defunction colon but reversal more difficult
11
Q
Location of end ileostomy:
A
right iliac fossa
12
Q
Use of end colostomy:
A
- colon diverted or resected
- anastomosis not primarily achievable or desirable
13
Q
Location of end colostomy:
A
left or right iliac fossa
14
Q
Use of loop colostomy:
A
- defunction a distal segment of colon
- both lumens present so distal lumen acts as vent
15
Q
Location of loop colostomy:
A
any region depending on colonic segment used
16
Q
Use of caecostomy:
A
stoma of last resort where loop colostomy not possible
17
Q
Location of caecostomy:
A
right iliac fossa
18
Q
Mucous fistula use:
A
- decompress distal segment of bowel following colonic division or resection
- where closure of distal resection margin not safe or achievable
19
Q
Location of mucous fistula:
A
any region of abdomen
20
Q
What are the borders of anal cancer?
A
- anorectal junction
- anal margin (area of pigmented skin around anal orifice)
21
Q
What type of cancer are most anal cancers?
A
80% squamous cell carcinoma
22
Q
Type of anal cancers:
A
- squamous cell
- melanomas
- lymphomas
- adenocarcinomas
23
Q
Which lymph nodes do anal cancers spread to?
A
- anal margin tumours - inguinal lymph nodes
- more proximal tumours - pelvic lymph nodes
24
Q
In which people are anal cancers more common?
A
- mwhswm - HPV
- females (1:2 ratio)
- older
25
Risk factors of anal cancer:
- HPV infection causes 80-85% of SCCs of anus
- anal intercourse
- mwhswm
- HIV or taking immunosuppressive medication
- women with Hx of cervical cancer or cervical intraepithelial neoplasia
- smoking
26
Symptoms of anal cancer:
- perianal pain
- bleeding
- palpable lesion
- faecal incontinence
- neglected tumour in female may present with rectovaginal fistula
27
Investigations used for anal cancer:
- T stage assessment: examination, anoscopic examination with biopsy and palpation of inguinal nodes
- imaging: CT, MRI, endo-anal US, PET
- test patients with HIV
28
Staging of anal cancer:
```
Tx - primary tumour cannot be assessed
T0 - no evidence
of primary tumour
Tis - carcinoma in situ
T1 - tumour <=2cm in greatest dimension
T2 - tumour 2-5cm
T3 - >= 5cm in greatest dimension
T4 - any size but invades adjacent organs (vagina, urethra, bladder) rectal wall perirectal skin, subcutaneous tissue, sphincter NOT classified as T4
```
29
What is an anal fissure and when is it chronic vs acute?
- longitudinal or elliptical tear of squamous lining
| - acute <6 weeks
30
Risk factors for anal fissures:
- constipation
- IBD
- STI e.g. HIV, syphilis, herpes
31
Features of anal fissures:
- painful, bright red, rectal bleeding
| - 90% posterior midline (other locations in e.g. Crohn's)
32
Management acute anal fissure <1 week:
- soften stool: dietary advice, bulk forming laxatives (lactulose if not tolerated)
- lubricants e.g. petroleum jelly before defecation
- topical anaesthetics
- analgesia
33
Management chronic anal fissure:
- acute techniques
- topical GTN first line
- if not effective after 8 weeks - consider surgery (sphincterotomy)
- botulinum toxin
34
Locations of colorectal cancers in order of prevalence:
- rectal
- sigmoid
- descending colon
- transverse colon
- ascending colon and caecum
35
Type of resection and anastomosis used in caecal, ascending or proximal transverse colon cancer:
- right hemicolectomy
| - ileo-colic
36
Type of resection and anastomosis used in distal transverse and descending colon cancer:
- left hemicolectomy
| - colo-colon
37
Type of resection and anastomosis used in sigmoid colon cancer:
- high anterior resection
| - colo-rectal
38
Type of resection and anastomosis used in upper rectum cancer:
- anterior resection
| - colo-rectal
39
Type of resection and anastomosis used in low rectum cancer:
- anterior resection
| - colo-rectal (defunctioning stoma)
40
Type of resection and anastomosis used in anal verge:
- abdomino-perineal excision or rectum
| - no anastomosis
41
Management when colonic cancer presents with obstructing lesion:
- stent or resect
- following resection, patients with risk factors for recurrence are offered chemotherapy, combination of 5FU and oxaliplatin common
42
How are rectal cancers resected?
- anterior resection or abdomen-preineal excision of rectum (APER)
- 2cm distal clearance margin
- also mesolectal fat and lypmh nodes
- can irradiate because exztraperitoneal unlike colonic
- obstructing rectal cancer: defunctioning loop colostomy instead because of high rate of anastomotic leak
43
Management of emergency perforation of bowel:
- increased risk of anastomosis especially colon-colon
| - end colostomy safer and can be reversed later
44
Hartmans procedure:
- sigmoid resection
| - end colostomy
45
Urgent referral guidelines for colorectal cancer (within 2 weeks):
- patients >=40yo with unexplained weight loss AND abdominal pain
- patients >=50yo with unexplained rectal bleeding
- patients >=60yo with iron deficiency anaemia OR change in bowel habit
- test shows occult blood in faeces
- consider if: anal mass/ulceration, 50yo with rectal bleeding AND pain, change in bowel habit, weight loss, iron deficiency anaemia
46
Who should be offered faecal occult blood testing?
- patients >=50yo with unexplained abdominal pain OR blood loss
- patients <60yo with changes in bowel habit OR iron deficiency anaemia
- patients >=60yo with anaemia or absence of iron def
47
When is CRC screening carried out?
every 2 years to all men and women 60-74 years (request over 74yo)
48
How is CRC screening carried out?
- faecal immunochemical test through post
- faecal occult blood test uses antibodies which recognises human haemoglobin
- quantifies amount of human blood in single stool sample
- abnormal results offered colonoscopy
- also flexible sigmoidoscopy screening
49
Why is flexible sigmoidoscopy used in CRC screening?
- to detect and treat polyps and reduce further risk
| - offered to 55yo
50
Usual site of diverticular disease:
between taenia coli where vessels pierce muscle to supply mucosa
-rectum spared
51
Diagnosis of diverticular disease:
- colonoscopy
- CT cologram
- barium enema
- critically unwell: plain abdominal films, erect CXR for perforation, abdominal CT with oral and IV contrast
52
Hinchey classification of diverticular disease severity:
I - para-colonic abscess
II - pelvic abscess
III - purulent peritonitis
IV - faecal peritonitis
53
Treatment of diverticular disease:
- dietary fibre
- mild: Abx
- abscess can be drained
- Hinchey IV perforations - resection and stoma
