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Rectum and Anus Flashcards

1
Q

What are the external and internal anal sphincters?

A

External anal sphincter is a continuation of the puborectalis muscle. Internal anal sphincter is a continuation of the muscularis propria.

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2
Q

What is the treatment for a thrombosed external hemorrhoid less than 72 hours old? Greater than 72 hours old?

A

Less than 72 hours old: surgery with elliptical excision.

Greater than 72 hours old: Lance open with elliptical incision.

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3
Q

Hemorrhoid grades

A

-Internal hemorrhoid classification:
i. Internal only
ii. Prolapse and spontaneously reduce
iii. Prolapse and manually are reducible
iv. Prolapse and are not reducible

Grade I do not prolapse with straining – First High fiber, 8 glasses of water a day
GII goes below anal verge, reduces spontaneously – First High fiber, 8 glasses of water a day
GIII manual reduction, GIV stuck

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4
Q

What are the symptoms of internal hemorrhoids?

A

-Division between internal and external hemorrhoids:
-Dentate/pectinate line
-Innervation is somatic below the dentate line and autonomic above (i.e. external hemorrhoids are painful)

-Common symptoms of hemorrhoidal disease:
-Bleeding, swelling, thrombosis
-Internal hemorrhoids predominately prolapse and bleed
-External hemorrhoids predominately present with pain after clotting

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5
Q

Rubber band ligation

A

– used for grade I or grade II
- Bands are placed 2 cm above dentate line
- Never band all 3. Band 1, then come back
- If patient returns after banding and is septic: Pelvic sepsis, admission, IV abx, to OR for EUA with drainage

-Internal hemorrhoids banded; risks= pain, bleeding, ulcer, small risk of Fournier’s gangrene
-Symptomatic/thrombosed external hemorrhoid can be excised; never choose banding or incision and drainage for external hemorrhoids.

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6
Q

What is the management for Grade II internal hemorrhoids?

A

GII goes below anal verge, reduces spontaneously – First High fiber, 8 glasses of water a day

Rubber band ligation – used for grade I or grade II
- Bands are placed 2 cm above dentate line
- Never band all 3. Band 1, then come back
- If patient returns after banding and is septic  Pelvic sepsis  admission, IV abx, to OR for EUA with drainage

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7
Q

Hemorrhoid indication for OR

A

Grade III, IV, or if patient has internal and external hemorrhoids

Strangulated, necrotic hemorrhoids need urgent hemorrhoidectomy

Should take both internal and external hemorrhoids intra-op.

Start from perianal skin to anorectal ring

Should take mucosa and submucosa down to internal sphincter

MC complication is urinary retention

Electrothermal device for hemorrhoidectomy – decreases post operative pain vs others

Stapled Hemorrhoidopexy – less pain, lower risk of incontinence, faster return to work than hemorrhoidectomy. Has higher rate of rectal prolapse, septic complications and tenesmus.

Transanal hemorrhoidal dearterialization: Doppler-guided arterial ligation with hemorrhoidopexy. Ligation of the superior rectal arteries along with suture rectopexy.

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8
Q

Prolapsed hemorrhoids vs rectal prolapse

A

Prolapsed hemorrhoids are described as starburst pattern with radial folds, while rectal prolapse is described as concentric rings

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9
Q

What device decreases postoperative pain in hemorrhoidectomy?

A

Electrothermal device.

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10
Q

Chronic constipation
Four types (causes)

A

Chronic constipation
Four types (causes)
- Colonic inertia (slow transit constipation)
- Pelvic floor dysfunction
- Mixed
- IBS

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11
Q

Workup for chronic constipation?

A

Steps for work up
1. Colonoscopy/contrast enema Rule out structural causes – CA, stricture
a. If no issues  start medical therapy  fiber + miralax  then wait for 6 months!!
b. If 6 months pass and fails, then below
2. Evaluate for pelvic floor dysfunction defecography and anal manometry
a. This rules out rectocele, sigmoidocele
3. Then investigate for colonic inertia with radiopaque marker study. If 20% or more radio markers present at day 5 = colonic inertia

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12
Q

What is the treatment for a patient with colonic inertia and no pelvic floor dysfunction?

A

Total abdominal colectomy with ileorectal anastomosis.

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13
Q

Rectal prolapse

A

90% females, with history of vaginal birth
Associated with fecal incontinence

Causes:
- Laxity of pelvic floor
- Weak internal and external sphincter
- Pudendal neuropathy
- Redundant rectosigmoid

Full thickness = circular fold
Partial mucosal prolapse = radial folds

All patients should get colonoscopy to look for rectal disease/CA

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14
Q

Rectal prolapse treatment

A

Tx: High fiber, stool softeners (AVOID LAXATIVES), hydration, defecation training

Surgery indicated for full thickness prolapse only: have to manually reduce or cannot reduce

Perineal procedures – If old, frail, would perform this!!!
- Delorme’s procedure (Mucosal Sleeve Resection)
- Treatment of choice for mucosal and short-segment prolapse
- 1 cm proximal to dentate, separate mucosa from muscularis. Excise mucosa
- Plicate muscularis to proximal mucosa

  • Altemeier’s Procedure (Perineal Rectosigmoidectomy)
  • Circumferential incision through all layers of rectum proximal to dentate
  • Reduce as much rectum out as possible
  • Transect prolapsed rectum
  • Can plicate levators to decrease incontinence then anastomose to anus

Abdominal procedures
- Rectopexy and sigmoid resection
- MC used and MOST effective
- Suture fixate rectum to presacral fascia

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15
Q

What is the treatment for full thickness rectal prolapse?

A

Surgery is indicated.

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16
Q

Solitary rectal ulcer syndrome

A

Caused by repetitive rectal prolapse causing anterior rectal ulcer
Highly associated with rectal prolapse
Dx: colonoscopy, also need to be evaluate for pelvic floor dysfunction (EMG, defecography) or even EUS
Tx: high fiber, etc.  medical management 1st. Surgery if that fails
If asymptomatic  leave alone
Surgery: If has rectal prolapse  Sigmoid resection with rectopexy

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17
Q

Anal fissure

A

Pain WITH defecation
90% posterior midline, distal to the dentate line
If lateral – think Crohn’s, cancer, syphilis
Chronic ones will have sentinel pile

Dx: rectal exam
<6 weeks of symptoms = acute anal fissure
>6 weeks = Chronic anal fissure

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18
Q

Anal fissure treatment

A

For acute: always start with fiber, water, stool softener.
For chronic  as above but if it fails  next step is nitroglycerin and diltiazem (both cause headaches), and botox. All of these suck, high recurrence rates
- If fails  EUA (look for other causes) and surgery
Right Lateral subcutaneous internal sphincterotomy (RADIAL incision of internal sphincter from dentate to anal verge) = Lowest recurrence rates
- Don’t perform in Crohn’s, don’t go past dentate line, don’t cut mucosa or external sphincter
- If patient has incontinence DO NOT DO sphincterotomy  Instead, a fissurectomy with an anocutaneous advancement flap is the procedure of choice

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19
Q

Anorectal abscess

A

Caused by obstructed anal gland/crypt (Crypts of Morgagni)

MOST DO NOT NEED ANTIBIOTICS AFTER DRAINAGE unless, cellulitis, septic, DM, steroid use, mechanical valve, immunocompromised

Perianal abscess – fluctuance near anal verge

Ischiorectal abscess – will have medial gluteal findings, no tenderness in digital rectal exam

Bedside drainage - can be done for perianal or ischiorectal

Intersphincteric abscess will show no findings on external exam of anus but significant pain with DRE
- Needs to be drained transanally

Supralevator = no findings on rectal exam. Need CT!
- These are caused by either intra-abdominal/pelvic pathology vs ascending cryptoglandular disease
- Descending abdomino/pelvic sources: Perform CT guided drainage
- Ascending cryptoglandular source 2 types:
- Transphincteric fistula (through sphincters and ischiorectal space) – DRAIN THROUGH ISCHIORECTAL SKIN
- Intersphincteric fistula: drain transrectally

Intersphincteric and ischiorectal can form horseshoe abscesses

Horseshoe abscess: radial incision in posterior anal verge to coccyx, with ellipitical counter incisions over ischiorectal area

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20
Q

Rectocele

A

– rectum bulges into vagina. RF multiparous. Tx: Fiber (treats majority). If significant sx - transvaginal reinforcement of pubocervical fascia

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21
Q

Anal incontinence

A

-MCC in women: obstetrical injury

Dx: Anal endosonography or EMG (anal manometry)– used to diagnose a defect in internal and external anal sphincters

Neurogenic (eg spinal cord injury): No good treatment. Tx: Colostomy

Abdominoperineal descent: Chronic damage to EXTERNAL anal sphincters. levator ani mm, puborectalis, and pudendal nerves (Obesity, Multiparous women). Anus falls below levator

Tx: First try Conservative, high fiber, limit to one BM a day.
-Surgery→ anterior anal sphincteroplasty, tightens external anal sphincters
-MC complication after surgery is stenosis: dilate

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22
Q

Anal stricture

A

Tx: 1st try fiber, then dilate. If medical tx maximized, then consider surgery = anoplasty (flaps)

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23
Q

What is the treatment for anal condyloma acuminatum?

A

Anal Condyloma accuminatum (Warts) – Verrucous, koilocytes
Tx:, Don’t use topical If large: imiquimod, 5FU, (podophyllotoxin rarely used)
Cryotherapy, argon beam, excision, fulguration

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24
Q

What is anal intraepithelial neoplasia associated with?

A

Anal intraepithelial neoplasia: precursor to SCC
Strongly associated with HPV, HIV, warts

AIN I – low grade dysplasia
AIN II – moderate dysplasia
AIN III – high grade dysplasia

Risk factors to SCC progression: HIV, HPV
Dx: biopsy suspicious lesions
Tx: Laser ablation, fulguration, cryotherapy, excision if large
Need surveillance

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25
Q

What is Bowen’s disease?

A

Bowen’s disease = perianal AIN III/SCC in situ
SCC in situ.
10% turn into SCC.
Scaly, erythematous, brown pigmented plaque
Will see high grade squamous intraepithelial lesion on pathology
Associated with HPV 16 and 18
Dx: Biopsy
Tx: Wide local excision, high recurrence rates

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26
Q

What is the treatment for Paget’s disease of the anus?

A

Paget’s of anus – severe intractable pruritus. Can present as mass. Eczematous rash. Biopsy this.
When this is found, has 50% risk of other visceral CA. -> Need colonoscopy and CT abdomen
Tx: This needs surgical excision

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27
Q

Squamous cell CA in Anal margin lesions (Anal margin = anal verge to surrounding skin within 5 cm)

A

Anal margin = anal verge to surrounding skin within 5 cm

Squamous cell CA in Anal margin lesions (Anal margin = anal verge to surrounding skin within 5 cm)
Treated almost the same as anal canal lesion
- Within 5 cm of anal verge
- Work up:
o CT chest abd pelvis
o Biopsy any suspicion nodes

  • Tx: Almost all are treated with Nigro protocol. Only < 2 cm lesions can be excised.
    o WLE for T1, N0 < 2 cm, no sphincter involvement, no nodes (need 1.0 cm margin)
    o If > T1 or positive nodes or > 2 cm or involves sphincter → chemo-XRT with (5FU and mitomycin).
    o If positive inguinal node  include it in XRT. No nodal dissection
    o APR and node dissection if cancer progresses and + nodes after chemo-rad or if it recurs
    o If metastatic  5FU and Cisplatin
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28
Q

Squamous cell CA in Anal canal (Anorectal ring to anal verge)

A

Anal canal = Anorectal ring (1-2 cm proximal to dentate line) to the anal verge)

  • 95% Associated with HPV, 16 and 18
  • Associated with males having sex with males, anal intercourse, immunosuppression
  • Risk factors for recurrence and worst prognosis: Size < 5 cm and > 2/3 circumference involvement
  • Work up:
    o CT chest abd pelvis
    o Biopsy any suspicion nodes
  • Tx: Nigro protocol Chemo-XRT with (5FU and mitomycin). No surgery.
    o If positive inguinal node  include it in XRT. No nodal dissection
    o APR if cancer persists after chemo-rad or if it recurs
    o If metastatic  5FU and Cisplatin
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29
Q

What is the treatment for adenocarcinoma in the anal canal?

A

Adenocarcinoma in Anal canal (Anorectal ring to anal verge)
- Tx: Abdominoperineal resectionusually
- WLE if < 3 cm, < 1/3 circumference, limited to submucosa (T1), need 3 mm margin no vascular/lymphatics/nerve, well differentiated
- Treat the same as rectal CA in regards to chemo-XR

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30
Q

What is the treatment for melanoma in the anal canal?

A

Melanoma in Anal canal (Anorectal ring to anal verge)
- Tx: Wide length excision!! Not APR. No difference in mortality between APR and WLE
- Follow normal guidelines for margin
- Median survival is 2 years

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31
Q

What is the treatment for basal cell carcinoma in anal margin lesions?

A

Basal cell CA in Anal margin lesions (Distal to anal verge)
- Tx: WLE usually sufficient with 3 mm margins.
- Rarely need APR unless sphincter involved

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32
Q

What is contraindicated for fistulotomy?

A

Elderly women with anterior fistula, fecal incontinence, Crohn’s, AIDS, high transphincteric fistula, extrasphincteric, suprasphincteric, recurrence
- Never do a fistulotomy in the setting of an acute abscess/infection

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33
Q

What is Goodsall’s rule?

A

Anterior openings connect to anus in straight line to anus (unless > 3 cm away from anus,). Posterior openings within 3 cm have curvilinear fashion and have internal opening in posterior midline

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34
Q

What is the best method to diagnose complex fistula anatomy?

A

MRI is best. ERUS also good

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35
Q

What is the treatment for persistent fistula?

A

Persistent fistula  endorectal advancement flap

Endorectal advancement flap – “Gold standard” sphincter preserving operation. Used as second stage procedure.
o Indications: High transphincteric, suprasphincteric, fecal incontinence, anterior fistula in women
o Never appropriate in the setting of an acute abscess/sepsis
o Flap created with mucosa, submucosa, and internal sphincter mm

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36
Q

What is the treatment for an abscess?

A

Draining seton or flap.

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37
Q

Seton

A

Setons – Used to allow sepsis to drain. can be used as definitive treatment, or a bridge to 2nd stage procedure (fistulotomy, flap)

  • Extrasphinteric: seton
  • Draining seton for all anterior fistula in women
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38
Q
  • Crohn’s fistula
A

Seton, flagyl, and infliximab are definitive management

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39
Q

What is the treatment for a persistent fistula?

A

Endorectal advancement flap.

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40
Q

What is the LIFT procedure used for?

A
  • Ligation of intersphincteric tract (LIFT) procedure
    o Performed as a second stage procedure (e.g. after seton)
    o used for complex TRANSPHNCTERIC fistula and recurrent fistula not amenable to fistulotomy alone
    o Widen external opening, 1-2 cm incision over intersphincteric groove, isolate fistula tract, ligate tract,
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41
Q

Fistula in ano
- Intersphincteric
- Transphincteric
- Suprasphincteric

A

Fistula in ano
- Intersphincteric (between sphincters) arise from perianal abscess: fistulotomy

Transphincteric arise from ischiorectal abscess (goes through external sphincter)
-If upper 2/3 (external anal sphincter) = Complex -> seton. NO fistulotomy. Consider endorectal advancement flap if recurs
-Lower 1/3: seton is safest, consider fistulotomy

Suprasphincteric arise from supralevator abscess draining seton or flap

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42
Q

What is the use of fibrin sealant or collagen plug?

A

Used after seton. No risk of incontinence.

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43
Q

What is the most common cause of colovesicular fistula?

A

Diverticulitis.

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44
Q

What is the most common cause of rectovaginal fistula?

A

Obstetrical trauma.

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45
Q

What characterizes a simple rectovaginal fistula?

A

Simple - = BELOW sphincter complex - means you can repair trans-anally.

Tx: wait 3-6 months because most of these heal spontaneously. Endorectal advancement flap it that fails.

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46
Q

What characterizes a complex rectovaginal fistula?

A

-ABOVE sphincter complex - means you have to repair it transabdominally.

Tx: Trans-abdominal or combined abdominal and perineal approach to do resection and anastomosis of rectum, close hole in vagina, bring down omentum, temporary ileostomy

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47
Q

What is the surgical anal canal length?

A

5 cm.

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48
Q

What is the dentate line?

A

Transition area of columnar to stratified squamous epithelium.

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49
Q

What does Denonvillier’s fascia separate?

A

Rectum and prostate in males; rectum from vagina in females (rectouterine pouch)

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50
Q

What does the rectovesical pouch separate?

A

Rectum from bladder.

51
Q

What does Waldeyer’s fascia separate?

A

Rectum from presacral venous plexus and pelvic nerves.

52
Q

What is the venous drainage above the dentate line?

A

Superior hemorrhoidal plexus.

53
Q

What is the venous drainage below the dentate line?

A

Inferior hemorrhoidal plexus.

54
Q

What is the nodal drainage for the anal canal above the dentate line?

A

Internal iliac nodes.

55
Q

What is the nodal drainage for the anal margin distal to the dentate line?

A

Inguinal nodes.

56
Q

What controls the external sphincter?

A

CNS voluntary control.

57
Q

What nerve innervates the external sphincter?

A

Inferior rectal branch of the internal pudendal nerve (sympathetic)

Is a continuation of the puborectalis muscle. Part of the levator ani muscle group. (striated)

58
Q

What is the internal sphincter under?

A

Involuntary control.

59
Q

What nerves innervate the internal sphincter?

A

Pelvic splanchnic nerves (parasympathetic) S2-S4.

  • Continuation of the muscularis propia (circular, smooth muscle)
  • Normally contracted

Unilateral injury to S1–3 nerve roots will not cause fecal incontinence because the patient can still maintain sufficient anal sphincter control, but bilateral injury to S1–3 nerve roots will cause fecal incontinence, as in this patient.

60
Q

What is the levator ani?

A

Marks the transition between anal canal and rectum.

61
Q

What is the most common cause of sigmoid volvulus?

A

Elderly patients with neuropsychiatric issues being treated with anti-psychotics and laxative abuse.

Bent inner tube sign. Points to RUQ

62
Q

What is the treatment for sigmoid volvulus?

A

-Contrast enhanced CT to confirm diagnosis and assess colon viability
-If no colonic ischemia or perforation on CT: endoscopic detorsion with decompression tube in place for 1-3 days
-High long-term recurrence rate after initial endoscopic detorsion; consider sigmoid colectomy during index admission in appropriate patients
-Emergent operation: open sigmoidectomy with end colostomy (Hartmann)
-Semi-elective after successful detorsion: open sigmoid colectomy with anastomosis

63
Q

What is the coffee bean sign associated with?

A

Cecal volvulus. Points LUQ

64
Q

What is the treatment for cecal volvulus?

A

Ileocecectomy or right hemicolectomy with primary anastomosis.

-Endoscopic reduction NOT recommended – rarely successful with high recurrence
-Need to go to OR; resect if dead bowel
-Resection vs pexy?
-Resection lower recurrence but higher procedure-related morbidity than pexy
-Safest answer = resection (ileocecectomy or right hemicolectomy) with primary anastomosis

65
Q

What is the management for frail and incontinent patients with cecal volvulus?

A

Colectomy with ileostomy and mucous fistula.

66
Q

What is the most common polyp?

A

Hyperplastic polyp, no cancer risk. Follow up q 10 years

67
Q

What is the most common neoplastic polyp?

A

Tubular adenoma. Mostly pedunculated

68
Q

What is the risk associated with villous adenoma?

A
  • Most likely to produce symptoms
  • High risk. 50% have cancer
  • Mostly sessile and larger than tubular
69
Q

What increases cancer risk in polyps?

A

Polyps > 2 cm, sessile, or villous.

“Sessile Serrated” – increased risk of CA

70
Q

What is high-grade dysplasia?

A

Basement membrane intact, carcinoma in situ.

Intra-mucosal CA – into muscularis mucosa (carcinoma in situ), still not through BM

71
Q

What defines invasive colorectal cancer?

A

Invasion into submucosa (T1).

72
Q

What are the criteria for adequate polypectomy?

A

2 mm margin, no deeper than T1 (submucosa), mod-well differentiated, no lymph/vascular/neuro invasion.

anything else would need a formal colectomy

73
Q

What is the treatment for extensive low rectal villous adenoma with atypia?

A

Transanal excision or mucosectomy.

74
Q

What defines an advanced adenoma?

A

Adenoma polyp > 1 cm, high-grade dysplasia, or villous/tubulovillous.

75
Q

When should screening colonoscopy start for average risk individuals?

A

At age 50, perform yearly. No screening colonoscopy after age of 85

76
Q

When should repeat colonoscopy occur if no polyps are found?

A

In 10 years.

  • no polyps
  • < 1 cm and < 20 hyperplastic polyps
77
Q

Needs screening at 40 (or 10 years before youngest) then colonoscopy every 5 years

A
  • One 1st degree relative with cancer or advanced adenoma found at age < 60
  • Two 1st degree relatives with colon cancer or advanced adenoma at any age
78
Q

Repeat Colonoscopy in 6 months

A

Adenoma removed in piecemeal fashion

79
Q

When should repeat colonoscopy occur for high-risk individuals?

A

In 3 years.

  • 5-10 Tubular adenomas
  • Tubular adenoma > 1 cm
  • Any advanced adenoma
  • Villous Adenoma or tubulovillous
  • Sessile serrated > 1 cm or with dysplasia
  • High-grade dysplasia
  • 5-10 sessile serrated
80
Q

When should repeat colonoscopy occur for > 10 adenomas?

A

In 1 year.

  • > 10 adenomas
  • Repeat Colonoscopy after colon cancer resection
81
Q

What are the screening options for colorectal cancer?

A

Screening options
- Fecal occult test every 1 year
- FIT immunochemistry every 1 year
- FIT DNA every 3 years
- Flex sig every 5
- CT colonography q 5
- False positive guaiac – beef, vitamin C, iron, cimetidine
- No colonoscopy with recent MI, splenomegaly, pregnancy (if fluoroscopy planned)

Fecal occult blood test (FOBT) – detects heme found in hgb and diet. Also detects bleeding from UGI and respiratory. High false positive. Has dietary restrictions before test.
- Screening yearly
Fecal Immunochemical testing (FIT) – Specifically detects human heme. Won’t detect UGIB. Specific to LGIB. Much more sensitive and specific than above. Lower false positive than above.
- Screening yearly
Multitarget stool DNA test FIT test (DNA FIT) – tests for abnormal DNA in stool for colon cancer. Performed with FIT test. Has high false positives.

82
Q

What is post polypectomy syndrome?

A

Post polypectomy syndrome - After colonoscopy and hot snare of large polyp, usually sessile

Patient present with pain, slight fever, slightly high WBC
They can have localized peritonitis
CT will show localized inflammation of colon around site of biopsy
No need for further studies with enteric contrast
Treatment: NPO and IV abx, unless the patient has diffuse peritonitis  OR

83
Q

What are the risk factors for colorectal cancer?

A

High BMI, sedentary lifestyle, DM II, red meat, smoking, alcohol.

84
Q

What is the chromosomal instability pathway for colorectal cancer?

A

1st loss of APC (tumor suppressor gene), 2nd activating mutation of KRAS, 3rd loss of P53 (tumor suppressor gene).

85
Q

What does CEA predict in colorectal cancer?

A

Prognosis if high, detects recurrence, and follows response to treatment.

86
Q

What is the best test to pick up metastasis in colorectal cancer?

A

Intra-hepatic ultrasound.

87
Q

What is the treatment for colorectal peritoneal carcinomatosis?

A

Cytoreductive surgery with HIPEC.

88
Q

Colorectal cancer: worse prognosis, pre-op; post-op

A

Worse prognosis with perf, ulceration, or obstruction

If unable to perform FULL colonoscopy before resection (obstruction, perf. Etc.): perform colonoscopy 3 months after surgery

After surgery for colorectal CA – need colonoscopy and CT at 1 year. CEA and H&P @ at 3 months

Surgical concepts:
- Need to perform en-bloc resection and remove any organ that is involved, if can get all of it

89
Q

What is the management for tumors at the transverse colon?

A

Extended right or extended left hemicolectomy. make sure to take all of middle colic

90
Q

What is the management for tumors at the splenic flexure/hepatic flexure?

A

Need extended right or extended left hemicolectomy.

91
Q

What is the procedure for low rectal cancer?

A

LAR = sigmoidectomy and proximal rectum.
o Where the rectum begins is controversial. EITHER the DENTATE LINE or ANORECTAL RING
o Needs at least 1-2 cm distal margin – needs to be 1-2 cm from levator ani muscles: if not -> APR
o Need at least 1-2 cm above anorectal ring to perform LAR, otherwise APR
o Anorectal ring = top border of the anal canal

92
Q

What is a contraindication to LAR?

A

Involvement of sphincter, levator ani, or incontinence.

93
Q

RHC
ERHC
LHC
SC

A

RHC: High ligation of ileocolic and right colic, and right branch of middle colic FOR BOTH BENIGN AND MALIGNANT; take terminal ileum too

ERHC- above but take middle colic at base

LHC for benign – take left colic and sigmoidal branches

Sigmoid CA: just take sigmoid down to sacral promontory; Low ligation of IMA, distal to left colic take-off

94
Q

APR

A
  • If patient has a proximal obstructive colon CA near ileocecal valve: perform RHC, and most cases can perform primary anastomosis
  • In all other cases – obstructive colon CA, perforation, fecal contamination cancer: perform colostomy
  • Tumor < 5 cm from the anal verge or at the dentate line, or involving sphincter/pelvic structures will: require APR.
  • Rectal pain with rectal CA (growing into sphincters, causes pain): APR
  • Colon CA margin > 5 cm
  • Low rectal trans anal excision T1, > 2 mm margin
  • Take Waldeyer’s and Denonvillier’s fascia in rectal CA
95
Q

What is the treatment for rectal cancer that is T3, T4, or + nodes (Stage II/III) ?

A

Pre-op chemo/radiation and then post-op chemotherapy only.

96
Q

What is the best predictor of local recurrence in rectal cancer?

A

MRI is best for T and N staging for rectal CA

Rectal cancer – T stage is the best predictor of local recurrence. Nodal status and CEA are not predictors of recurrence.

97
Q

Pre-op Chemo-XRT for rectal cancer

A

Pre-op Chemo-XRT for rectal cancer decreases local recurrence, allows for sphincter preservation, and preserves continence. Does not alter survival.
Neoadjuvant chemo XRT can provide complete pathological response (based on restaging biopsy) in 10-30% of patients. This can be followed for evidence of recurrence.
- Rectum split in thirds, measured from anal verge (includes anal canal)
- 0-5 cm (distal), 5-10 cm (middle), and 10-15 cm (proximal).
- At 15 cm, this is the rectosigmoid junction
- Neoadjuvant chemo/rad for stage II and III is best for middle and distal rectal cancer (decreases local recurrence). Does not decrease local recurrence for proximal rectum.
- Treat proximal rectum cancer like colon cancer

98
Q

What is the indication for colonic stent placement?

A

Colonic stent for malignant obstruction
Used for malignant colon obstructions only
Used only for left sided colon cancer: sigmoid, rectum, descending colon
Stents increase likelihood to perform laparoscopic resection
Significantly lower risk of SSI if stent placed vs emergent surgery
Stent migration is highest when stent is in the rectosigmoid junction

Indications:
- Palliation for incurable colorectal cancer -> Stent is preferred OVER SURGERY with metastatic disease
- Stenting as a bridge to avoid emergent surgery
- Management for extracolonic pelvic tumors (ovary) causing obstruction

99
Q

What are the contraindications for colonic stents?

A

Complete obstruction and distal rectal obstruction 1-5 cm proximal to anal verge.

100
Q

What is the goal of total mesorectal excision?

A
  • Sharp dissection
  • Avoid sympathetic hypogastric nerves and parasympathetic S2-S4. Causes bladder, sexual dysfunction, retrograde ejaculation
  • Need 2 mm circumferential (radial) margin
  • Distal margin 2 cm, but 1 cm is acceptable
101
Q

What are the criteria for transanal excision of low rectal adenocarcinoma?

A

T1, < 8 cm from anal verge, < 3 cm in size, < 30% circumference, clear margin (>3 mm), mobile, non-fixed, well differentiated, no LN involvement or vascular invasion. No signet cell or mucinous component.

Everything else needs APR or LAR

102
Q

What is the chemotherapy regimen for stage III, IV colon cancer?

A

Colon CA stage III, IV – adjuvant chemo – 6 months of FOLFIRI or FOLFOX
- T4a – penetrates visceral peritoneum
- T4b – penetrates other organs

103
Q

What is the neoadjuvant treatment for rectal cancer stage II or greater?

A

Rectal Ca – stage II or > need neoadjuvant chemo-RAD, and post op chemo
- 5-6 weeks of chemo-rad then surgery in 3-4 weeks

104
Q

What is the first line chemotherapy for colorectal adenocarcinoma?

A

5FU, leucovorin, and irinotecan (FOLFIRI). Add Bevacizumab (Avastin) if metastatic cancer

105
Q

What is the second line chemotherapy for colorectal adenocarcinoma?

A

5FU, leucovorin, oxaliplatin (FOLFOX).

106
Q

High risk stage II colon cancer

A

High risk stage II colon cancer needs adjuvant chemo, high risk = perforation, obstruction, poor differentiation, lymphovascular invasion, positive margin or < 12 nodes collected

107
Q

What is the treatment for metastatic cancer with EGFR positive?

A

Cetuximab only if EGFR positive (wild type KRAS) and metastatic

Bevacizumab if metastatic (VEGF inhibitor)

108
Q

What is the best approach for resecting liver metastases in colon cancer?

A

When resecting liver mets, do not need anatomical resection, wedge resection is best

109
Q

Controlling nausea

A
  • Don’t use drugs of similar action, especially D2 antagonist (Dystonia, akathisia)
  • Instead use drugs of different action when combining
  • Aprepitant stimulates NK1 receptors
  • Cannabis is not FDA approved for chemo induced nausea
  • Metoclopramide, chlorpromazine, haloperidol and prochloperazine all are D2 antagonists
  • Ondansetron is a 5HT3 serotonin antagonist
110
Q

What does Aprepitant do?

A

Stimulates NK1 receptors

111
Q

What are examples of D2 antagonists?

A

Metoclopramide, chlorpromazine, haloperidol and prochloperazine

112
Q

What type of antagonist is Ondansetron?

A

Ondansetron is a 5HT3 serotonin antagonist

113
Q

Radiation complications

A

Damage caused directly to DNA and by radical oxygen species
Usually need at least 4000 cGy of radiation
Chemotherapy, vascular disease, and diabetes increases radiation damage
Steroids are not used to treat radiation complications
Acute radiation damage (< 3 months): Mucosal cell damage.
Chronic (> 3 months): obliterative arteritis of submucosal vessels

114
Q

What are the symptoms of acute radiation proctitis/enteritis?

A

1 Anti-diarrheal, anti-spasmotic (Most resolve). Never really need surgery here

Acute Radiation proctitis/enteritis (within 3 months of radiation)

Symptoms: diarrhea, mucous discharge and tenesmus #1Anti-diarrheal, anti-spasmotic (Most resolve). Never really need surgery here

115
Q

Chronic radiation enteritis?

A

Chronic radiation Enteritis – chronic diarrhea, steatorrhea, weight loss  Treatment  anti-diarrhea loperamide
- Only operate for chronic radiation enteritis/colitis/proctitis: ONLY indications: bleeding, perforation, obstruction, fistula
- Liberal use of bypass here! Stop if making enterotomies
- Never do strictureplasty or extensive lysis of adhesion

116
Q

What are the symptoms of chronic radiation proctitis?

A

Chronic radiation proctitis
- Symptoms: Rectal bleeding and strictures!!!
- dx: Need endoscopy
- Tx: 1st line treatment of chronic radiation proctitis = Sucralfate enemas!!!!
- If major issue is bleeding  formalin fixation enema as 2nd line. Really good for bleeding
- If this fails and especially in bleeding Endoscopic Argon beam is also good
- If symptom is stricture  low residue diet, stricture dilation. If refractory  divert with ostomy (last resort)
- If symptom is fistula  conservative management.
- NO APR for radiation proctitis

dx: Need endoscopy

117
Q

What is the second line treatment for bleeding in chronic radiation proctitis?

A

If major issue is bleeding –> formalin fixation enema as 2nd line. Really good for bleeding

118
Q

Lynch Syndrome

A

Defect in DNA mismatch repair gene – MSH2, MSH6, MLH1, PMS1, PMS2 – these will not be produced in Lynch syndrome

Sporadic tumors can still have the above defective

DNA mismatch repair genes

Characterized by microsatellite instability

Amsterdam criteria – 3 family members (must be first degree), over 2 generations, 1 relative with CA before 50. FAP must be excluded

Surveillance colonoscopy at 20-25 or 10 years before primary relative, with repeat every 1 or two years

Need transvaginal US or endometrial aspirate yearly starting at 20 years old

Needs total abdominal colectomy with ileorectal anastomosis with first colon CA operation

  • Also recommend prophylactic hysterectomy and bilateral salpingo-oopharectomy if patient does not want children

Highest risk of CA: colorectal and endometrial!!!!
Also have risk of ovarian, endometrial, bladder, pancreas, stomach

Also need transvaginal US/endometrial aspiration yearly starting at 35-40, q1 year

EGD for stomach CA starting at 30-35 Q1 year

Cystoscopy and US for GU CA @ 30-35 Q1 year

119
Q

What is FAP?

A

FAP – Autosomal dominant, chromosome 5
Mutation in APC gene.
Risk of colorectal, gastric, duodenal CA, medulloblastoma, osteoma
All have CA by 50
100-1000 polyps
Mostly left sided colon polyps, can have duodenal and stomach too
Remove all polyps found in duodenum
Colonoscopy/flex sig by 10-12 years. EGD by 20 years old
Need total proctocolectomy with J pouch by age 20
if any adenomatous polyps found at ANY age: proctocolectomy with IAA

-If undergo total abdominal colectomy with ileorectal anastomosis: should undergo yearly endoscopic surveillance of their rectum

120
Q

Colon anatomy/ blood supply

A

-Cecal diameter > 9 cm is abnormal
-Retroperitoneal portions of the colon: ascending, descending
-Blood supply:
-Superior mesenteric artery
-Terminal branch= ileocolic artery -> TI, cecum
-Right and middle colic arteries -> ascending and proximal 2/3rd of the transverse colon
-Inferior mesenteric artery
-Left colic -> distal 1/3rd of the transverse colon and descending
-Sigmoid branches -> sigmoid colon
-Superior rectal artery -> proximal rectum
-Collaterals
-Marginal artery -> along the colon wall connecting SMA and IMA
-Arc of Riolan (meandering mesenteric artery) ->smaller connection bn SMA and IMA
-Watershed areas:
-Splenic flexure: SMA/IMA connection (Griffith’s point)
-Rectal/sigmoid: superior/middle rectal artery connection (Sudeck’s point)

121
Q

Rectum anatomy/ blood supply

A

-Blood supply to rectum:
-Superior rectal (hemorrhoidal) artery - branch of IMA
-Middle rectal (hemorrhoidal) artery - branch of internal iliac (hypogastric) artery
-Inferior rectal (hemorrhoidal) artery- branch of internal pudendal from internal iliac
-Venous drainage of rectum:
-Superior rectal vein -> IMV -> portal circulation
-Middle and Inferior rectal veins -> internal iliac vein -> systemic circulation

-Proximal & distal extents of rectum:
-Proximal starts where taeniae splay
-Distal= anal canal (15 cm from anal verge)
-Anal canal
-Begins at puborectalis sling (anorectal ring), ends at anal verge = squamous mucosa blending with the perianal skin
-Anal margin
-Extends 5 cm radially from squamous mucocutaneous junction
-Main nutrient of colonocytes= butyrate (short chain fatty acid); glutamine 1ary source for small bowel enterocytes

122
Q

Transanal excision

A

Anal adenocarcinoma stage determined by depth of invasion rather size

Transanal excision: smaller than 3 cm, occupy less than 40% of the circumference of the lumen, proximal extent of the tumor must be palpable on DRE (>8 cm from the anal verge)

123
Q

Obstructing mass in the ascending colon

Righ

A

Right-sided obstructing colon cancer= right hemicolectomy with ileocolic anastomosis
-Diverting stoma rarely indicated due to low leak rates

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