Colorectal surgical problems

Question 1

Diverticular disease

Answer 1

• Almost always occur in colon (almost always in sigmoid colon)
• Diverticula are acquired and false (only consist of mucosa and submucosa)
• Risk factors: old age, diet poor in fiber
• They are outpouching of the mucosa and submucosa that extend past the muscularis externa/serosa layers
• These outpouchings travel along blood vessels that penetrate the layers of the colon, since these are the sites the muscle wall is weakest
• High pressures caused by stools (esp. constipation) contribute to the formation of diverticula
• Presence of diverticula is diverticulosis, perforation/infection of diverticula is diverticulitis

Question 2

Diverticulosis

Answer 2

• 80% of pts w/ diverticulosis are ASx
• Common Sxs include episodic LLQ pain/tenderness (usually sigmoid), constipation (more likely) or diarrhea (less likely)
• Can Dx diverticulosis by colonoscopy (usually done when bleeding to differentiate from CRC)
• 2 complications of diverticulosis: bleeding (erosion of the vessel its traveling along) and progression to diverticulitis
• Therefore its important for pt to tell you if there is blood per rectum, increased pain in LLQ w/ fever (could be diverticulitis)
• Rx of diverticulosis: in ASx pts more fiber in diet plus education, can undergo surgery if massive hemorrhage

Question 3

Diverticulitis 1

Answer 3

• Sx: acute abdominal pain (aching)/tenderness/masses (LLQ usually), N/V, fever and leukocytosis (these two are necessary for diverticulitis)
• Leukocytosis is mild-moderate, fever usually low-grade
• Acute diverticulitis is due to perforation or infection of diverticula
• Microperforations lead to localized inflammation-> abscess-> generalized peritonitis
• Complications: perforation and abscess formation, fistulization (usually colo-vesicular, usually in men), stricture leading to obstruction, sepsis

Question 4

Diverticulitis 2

Answer 4

• CT scan is both diagnostic and therapeutic
• Rx of diverticulitis: if expectant Rx then NPO and IV antibios, if peritonitis must go to OR (goal is one stage surgery), if abscess then CT to confirm and drain (CT-guided drainage)
• 1/3rd of medically Rx pts will recur in 5 yrs
• Indications for sigmoidectomy: persistant diverticulitis, inability to rule out CA
• No longer indications: <40, recurrent disease

Question 5

Surgical options in CRC

Answer 5

• Excision is based on vascular and lymphatics near the lesion
• Always do a staging CT scan, but CA is usually resected even in presence of mets
• Choice of operation depends on the height of the lesion above the dentate line (transition from columnar to squamous)
• Always desirable to preserve anal sphincters and avoid colostomy
• Abdominoperineal resection: distal sigmoid, rectum, and anus are removed
• Total mesolectal excision: just distal sigmoid and rectum removed (anus spared- preferred)

Question 6

Intestinal stomas

Answer 6

• Opening of the bowel onto the surface of the abdomen
• Both temporary and permanent stomas exist
• Are most often created during the 2 step surgical procedures

Question 7

Ileostomy

Answer 7

• Terminal ileum brought to surface thru rectus abdominus, there is continuous discharge and appliance must be worn at all times
• Leads to physiologic changes due to loss of H2O and salt (Na and K) absorption capacity of the colon
• Sxs to watch out for: anorexia, irritability, HA, drowsiness, cramps, thirst (indicated dehydration/salt deprivation)
• Complications of ileostomy: skin irritation (most common, due to bile salts on skin), obstruction, retraction, prolapse, abscess, diarrhea, gallstone/kidney stones

Question 8

Colostomy

Answer 8

• Indications: decompress obstructed colon, diversion of fecal stream (i..e preparation for resection), evacuation of stool if rectum/anus is resected, protection of distal anastomoses
• Complications: parastomal hernia, prolapse, necrosis/retraction
• Skin irritation unlikely b/c bile salts have been absorbed

Question 9

Laparoscopy

Answer 9

• Quicker recovery and discharge, fewer complications, less pain/scarring
• Still use general anesthesia, still injures organs/structures