RECTUM / ANUS Flashcards
Neoadjuvant therapy for rectal cancer
T3/4 lesions
of course nodes positive
5 fu
35 gray radiation
Treatment of anal squamous cell
5-FU
Mitomycin
Radiation
Careful, adenocarcinoma of the anus gets full APR
Careful, squamous cell the anal margin gets wide local excision
Where are Sentinelle nodes found for anal cancer
Inguinal anus
Treatment of positive sentiment notes for anal cancer
Radiation to nodal basin
Treatment of pilonidal cyst
Paramedian incision
elips of abscess
Rotational flap
Typical site for anal fissure
Posterior number one
Can also be anterior
Atypical lateral fisher consistent with Crohn’s
Treatment ladder for Crohn’s disease medications
sulfa salisine Five ASA Remicade TNF Monoclonal antibody
Rubber band ligation (RBL)
is suitable for Grades II and III hemorrhoids. This office procedure is performed in the Sims or prone jackknife position, using either a McGivney/Barron hemorrhoid ligator or a vacuum-assisted device (Figure 4). It is better to treat each hemorrhoidal complex individually to prevent postprocedural pain and undesirable protrusion. Placement of the band at least 5 mm cephalad to the dentate line reduces the incidence of postprocedural pain. Appropriately placed bans occasionally result in minor postprocedural discomfort for up to 24 hours, which is easily controlled by acetaminophen or nonsteroidal antiinflammatory drugs (NSAIDs).
Severe pain immediately after the procedure usually indicates placement too close to the dentate line and is treated with cutting the band using a specifically designed cutting hook.
band a maximum two pedicles, especially during the first encounter. If more than three sessions are required to control symptoms, hemorrhoidopexy or hemorrhoidectomy should be offered.
Closed hemorrhoidectomy (Ferguson hemorrhoidectomy)
for internal hemorroids
prone jackknife (preferred) or lithotomy position under local, regional, or general anesthesia, with the gluteal folds retracted with tape.
Antibiotics are not administered routinely!
A Hill-Ferguson retractor is placed in the anal canal and the hemorrhoid grasped at the perianal skin, the mucocutaneous junction, and the apex of the hemorrhoid.
Dilute epinephrine solution is injected to reduce bleeding during dissection and to spare the superficial external sphincter.
A diamond-shaped incision (scalpel/electrocautery) is made from the perianal skin into the anal canal and tapered toward the apex of the hemorrhoid. It is important to dissect superficial to the fibers of the internal sphincter, which is readily recognized due to its white muscle fibers.
The apex of the hemorrhoid is clamped and suture ligated with 2-0 absorbable suture and the wound closed with accurate mucosa to mucosa approximation.
The mucosa is fixed to the underlying sphincter muscle to recreate a new dentate line. The suture line continues into the perianal skin.
The tail of the apical suture is left long for identification of the pedicle in case of postoperative hemorrhage.
Dibucaine-impregnated Gelfoam is placed in the anal canal.
Patients are discharged the same day with narcotic and NSAID pain medications, Sitz baths, and stool softeners and are seen 10 days after surgery.
They are instructed to keep dry gauze in between the buttocks and change it two or three times a day.
The advantage of this technique is faster healing, but it also has the disadvantage of occasional wound infection and fistula formation.
The success rate of this technique in the long-term follow-up period exceeds 90%.
Figure 7 Ferguson hemorrhoidectomy (closed hemorrhoidectomy).
Hemorrhoidectomy in patients with active anorectal Crohn’s disease
should not be performed because of an increased risk of nonhealing, local complications, major incontinence, and subsequent need for proctectomy.
Patients with quiescent ileal or colonic disease undergoing conservative hemorrhoid surgery have a 90% healing rate at 2 months.
Procedures used in the control of bleeding anorectal varices in portal hypertension patient
direct suture ligation;
stapled anopexy;
SHUNTS!
transjugular portosystemic shunt;
mesocaval,
mesorenal,
and
sigmoid to ovarian vein shunts.
Goodsall’s rule
“Anterior is straight and direct”
“Posterior is curved all leading to one place - the posterior midline (crooked backdoor)”
predicts the location of the internal opening based on the location of the external opening
External fistula openings located posteriorly typically have internal openings in the posterior midline and a curved tract.
Anteriorly
radial course to the internal opening.
Exceptions to Goodsall’s rule
external fistula openings
greater than 3 cm from the anal verge anteriorly.
These likely have internal openings in the posterior midline.
A seton is commonly used in
anal fistulas that cannot be treated with primary fistulotomy alone.
High transphincteric fistulas, suprasphincteric fistulas,
anterior fistulas in women and in patients with HIV or Crohn’s disease typically have a seton placed as part of the treatment.
heavy-duty, nonabsorbable braided sutures that promote fibrosis and maturation of the tract before a definitive operation,
either fistulotomy or a sphincter-sparing procedure (Figure 8).
This may be performed in conjunction with a partial fistulotomy in which the distal part of the internal sphincter is divided and the seton placed in the remaining tract.
The fistulotomy is then completed 8 to 12 weeks later once the first stage has healed.
second use of the seton:
seton as the definitive procedure or in whom fibrosis is not desired (e.g., because of Crohn’s disease or advanced HIV).
vessel loop may be used as a seton to allow for drainage and prevent recurrent abscess formation (see Figure 8).
third technique:
cutting seton.
skin overlying the fistula tract is opened, and a heavy braided suture, vessel loop, or rubber band is placed into the fistula tract and tied snugly.
This is then tightened every 1 to 2 weeks with suture or rubber band placed via a hemorrhoid ligature, allowing for pressure necrosis to slowly cut through the sphincter muscles. This technique can result in significant incontinence rates and is used infrequently.
Endorectal advancement flaps
were originally described in 1912 by Elting and are used as an alternative to cutting procedures. Endorectal advancement flaps are commonly performed in high transphincteric fistulas, in low transsphincteric fistulas in women, and in Crohn’s fistulas if the patient has normal rectal mucosa. Endorectal flaps can be performed as a primary procedure or subsequent to seton drainage (Figure 9). The fistula tract should be curetted, and the internal opening is then excised. A flap of mucosa, submucosa, and superficial circular muscle is created, extended 4 to 6 cm proximal to the internal opening to allow for a tension-free closure. The base of the flap provides the blood supply to the flap and should be twice the width of the apex of the flap. The internal opening is then closed with absorbable suture, and the flap then advanced and sutured to the dentate line. The external opening is widened to allow for drainage. This procedure is not appropriate for fistulas with internal openings that are distal to the dentate line. If the flap is sutured too distal, then the result is a mucosal ectropion. Success rates for this procedure range from 75% to 98%
LIFT
Ligation of intersphincteric fistula tract
Curvilinear incision is made lateral to the intersphincteric groove
The internal sphincter and an external sphincter muscles are separated
A probe is placed with in the fistula tract
The track is isolated as circumferentially with in the space between the two sphincter muscles
The Vista tract is then ligated proximally and distally with adorable sutures after the program has been removed
The track is then divided and or excised
The incision is closed with chromic
The original external fistula opening is widened for drainage
