Surgery (3)

Question 1

Risk factors for colorectal carcinoma

Answer 1

• neoplastic polyps
• IBD (UC>CD)
• smoking
• previous cancer
• familial cancer syndromes (HNPCC, FAP)

Question 2

Most common colorectal carcinomas

Answer 2

Type: adenocarcinoma (95%)

• rectum 45%
• sigmoid 25%

Question 3

Pathophysiology of colorectal carcinoma

Answer 3

Mutations in WnT (pathway that regulates calcium inside the cell) → APC mutation → p53 → p53 x2 → malignancy

Question 4

Spread of colorectal cancer

Answer 4

Most spread haematogenously to the liver via the portal system

Question 5

Symptoms of R and L sided colorectal Ca

Answer 5

• Right-sided lesions: weight loss and IDA
• Left-sided lesions: PR bleeding, altered bowel habit or large bowel obstruction

Question 6

What can be seen on examination of a patient with colorectal carcinoma

Answer 6

• General examination may show signs of iron-deficiency anaemia (pallor, koilonychia, angular stomatitis)
• Palpation may reveal hepatomegaly (metastases)
• PR examination may reveal a palpable mass

Question 7

Ix for colorectal cancer

Answer 7

• Bedside – Faecal occult blood test
• Bloods – FBC (microcytic anaemia), LFTs (metastases), CEA (tumour marker)
• Imaging – Chest X-ray (metastases), USS Liver (metastases), CT/MRI (staging)
• Invasive – Colonoscopy (visualise lesion and biopsy).

Question 8

Duke staging for colorectal ca

Answer 8

Duke A

Tumour confined beneath muscularis mucosae (90% Five year survival)

Duke B

Tumour extension through muscularis mucosae (65% Five year survival)

Duke C

Involvement of regional lymph nodes (30% Five year survival)

Duke D

Distant metastases (<10% Five year survival)

Question 9

(4) types of surgery for colorectal Ca

Answer 9

Question 10

What R hemicolectomy is used for?

Answer 10

Right hemicolectomy for :

caecal, ascending and proximal transverse colon tumours

Question 11

What Left hemicolectomy is used for?

Answer 11

Left hemicolectomy for distal transverse colon or descending colon tumours

Question 12

What sigmoid colectomy is used for?

Answer 12

For sigmoid tumours

Question 13

What anterior resection is used for?

Answer 13

Anterior resection:

• low sigmoid
• high rectal tumours

If concerns around the primary anastomosis, a loop ileostomy can be created and reversed in the future

Question 14

What’s Total mesorectal excision used for?

Answer 14

Total Mesorectal Excision:

for rectal tumours with removal of surrounding fatty

tissue and nodes

Question 15

What’s abdominoperineal resection used for?

Answer 15

Abdomino-perineal (AP) resection

• low rectal tumours (

Results in an end colostomy

Question 16

What’s Hartmann’s procedure used for?

Answer 16

Hartmann’s procedure

• patients presenting as an emergency with large bowel obstruction
• results in an end colostomy
• it is temporary and the two parts of the bowel are re-joined in a later surgery (6 months later)

Question 17

Criteria for 2ww referral for colorectal cancer

Answer 17

2-week wait referral guidelines for

colorectal cancer:

• iron-deficiency anaemia >/60
• unexplained change in bowel habit >/60
• unexplained rectal bleeding >/50
• abdominal pain + weight loss >/40

Question 18

What number of stoma openings are indicative of?

Answer 18

Number of openings:

2 = loop

1 = end

Question 19

(3) types of stomas comparison
- location
- content
- opening
- indication

Answer 19

Question 20

Complications of stoma (mnemonic)

Answer 20

FOUL SHITS

Fluid loss

Odour

Ulceration of skin

Leakage

Stenosis

Herniation

Ischaemia

Terminal ileum loss

Sexual and psychological problems