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Colon, Rectum, Anus

Oral exam tutoring and summary
facebook: Happy Friday Knight

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Colon, Rectum, Anus

  1. 1. COLON, RECTUM, ANUS FACEBOOK: HAPPY FRIDAY KNIGHT ORAL EXAM TUTORING AND SUMMARY
  2. 2. IMPORTANT!!!!  Lt sided colonic obstruction  Colorectal liver metastasis (CRLM)  Lt sided diverticulitis  Benign anorectal diseases: anorectal infection, hemorrhoid, rectal prolapse
  3. 3. Lt sided colonic obstruction from CRC: choices  (For right sided obstruction: Rt hemicolectomy)  Endoscopic colonic stenting (self-expandable metallic stent (SEMS)  Bridging to surgery (preoperative decompression)  palliation  Loop colostomy/ileostomy  Segmental resection with end colostomy (Hartmann Procedure: 2 stages)  Total/subtotal colectomy  Segmental resection with primary anastomosis  With on-table lavage  With manual decompression (ref: ศัลยศาสตร์ทั่วไป เล่มที่ 20)
  4. 4. SEMS  Pallliation or bridging to surgery  Advantages: only 1 stage surgery  Complications:  Stent obstruction  Perforatioin  migration  Contraindication: colonic perforation, distal rectum < 5cm from AV (pain, tenesmus, fecal incontinence)  No role in proximal colonic obstruction  Be careful in patients receiving bevacizumab
  5. 5. Loop colostomy/ileostomy  Prefer in primary unresectable rectal cancer  No!!! End colostomy  Transverse colostomy in patients planned for LAR  Sigmoid colostomy in patients planned for APR
  6. 6. Hartmann’s procedure  Easy  2-stage: some patients did not get to have a second operation
  7. 7. Total/subtotal colectomy  Indications  Cecal serosal tear  Synchronous lesion  Complications: diarrhea
  8. 8. Segmental resection with primary anastomosis  Only in experienced surgeons and be careful of anastomotic leakage  On table lavage VS manual decompression  OTL: more SSI  Technique: don’t forget to fully mobilize colon
  9. 9. CRLM  Synchronous: worst prognosis  Metachronous  Early < 12 month  Late > 12 month : better prognosis
  10. 10. CRLM: METACHRONOUS  Resection  Neoadjuvant chemotherapy
  11. 11. CRLM: synchronous  Chemotherapy-first  Liver-first  Colon-first  simultaneous
  12. 12. CRLM: CMT-first  CMT  liver resection  CMT  CRC resection  Used in extensive liver metastasis  High CEA  +ve LN  Tumor > 5
  13. 13. CRLM: liver-first  Liver resection + ostomy  chemotherapy  colorectal resection  Used in asymptomatic CRC but extensive liver metastasis
  14. 14. CRLM: colon-first  Used in symptomatic CRC:  Perforation  obstruction
  15. 15. CRLM: simultaneous  Low tumor burden both CRC and liver
  16. 16. Lt sided diverticulitis  Hinchey Classification  CT  Techniques
  17. 17. Lt sided diverticulitis: Hinchey  Described colonic perforation due to diverticulitis  I: pericolic abscess  II: pelvic , intraabdominal, retroperitoneal abscess  IIA: amendable to PCD  IIB: with fistula  III: generalized purulent peritonitis  IV: generalized fecal peritonitis
  18. 18. Lt sided diverticulitis: CT 1. Thickening of colonic wall > 4 mm 2. Pericolic fat stranding 3. Diverticula with contrast/air/fecal inside 4. Pericolic, extrapelvic abscess 5. Fistulous tract 6. Stricture/SBO/ureteric obstruction 7. Extravasation of contrast/extraluminal air  perforation
  19. 19. Lt sided diverticulitis: technical consideration  Extension:  Proximal: just inflamed segment  Distal: upper rectum  No diverticula at anastomosis  leakage  Always perform leak test  If cancer is suspected  go on oncologic resection  Ureteric stent (ureteric injury 1%)  Elective surgery for Hinchey I-II: Resection with primary anastomosis with or without ostomy  Emergency surgery for Hinchey III-IV:  Hartmann  RPA with protective ileostomy
  20. 20. BENIGN ANORECTAL DISEASES  Anal pain  Hemorrhoid  Anorectal infection  Rectal prolapse
  21. 21. ANAL PAIN: DDx  Anal fissure  Thrombosed/strangulated hemorrhoid  Anorectal abscess  Fournier gangrene  Obstructed CA rectum  Retain foreign body  Acute proctitis  Proctalgia fugax: sphincter spasm
  22. 22. Technical Notes for Urgent Hemorrhoidectomy from Lohsiriwat V.  Preoperative antibiotics  Adequate analgesia and anesthesia  Manual reduction first to reduce edema  Anoderm or mucosa-sparing  > 1 cm mucosal bridge  > 50% of good circumferential mucosa  Vicryl 2. 3-0 for mucosal approximation  Plication of hemorrhoid may be used for small lesions  Oral metronidazole and flavonoid for 1 week
  23. 23. Anorectal infection  Anorectal abscess  FIA  Fournier gangrene
  24. 24. summary of Anorectal infections Definition in this summary = anorectal abscess and fistula-in-ano or anal fistula Anorectal abscess = acute condition Fistula-in-ano = chronic condition Fistulous abscess = simultaneous Facebook: Happy Friday Pathogenesis: Anal gland (at crypt) obstruction  stasis  infection For fistula-in-ano: infection  epithelialization to fistula Predominant organisms: Mixed: E.coli (22%), Enterococcus spp. (16%), Bacterioides fragilis (20%) History taking: pain, swelling, diarrhea Physical examination: - Look around buttock and anus - PR if not severe pain or no lesion - Proctoscopy and sigmoidoscopy in fistula-in-ano (anorectal abscess is painful so no proctoscope) Investigations: mostly done in diificult FIA and recurrence  fistulograpy, endoanal US, MRI, BE, colonoscope Conditions that antibiotics have the role: Extensive cellulitis Systemic signs of infection (sepsis) Immunocompromised host: DM, valvular heart disease, HIV Atypical microbes: TB, actinomycosis
  25. 25. summary of Anorectal infections Facebook: Happy Friday Content Anorecal abscess Fistula-in-ano History taking Pain with swelling, Predisposing diarrhea, Bleeding per rectum Discharge, Pain (34%), Swelling, Bleeding, Diarrhea Physical exam Redness, Heat, Swelling (not in intersphincteric abscess), pain, Loss of function, Mass when PR (mostly impossible to PR), Pus exuding, Inguinal LN enlargement External opening: granulation Purulent serosanguinous discharge when compression Goodsall’s rule: • Opening posterior to coronal plane: fistula originates from dorsal midline • Opening anterior: runs directly to nearest crypt example
  26. 26. summary of Anorectal infections Content Anorectal abscess Fistula-in-ano classification In supralevator abscess: determine to origin  ischioanal, intersphincteric, or pelvic (diverticulitis, appendicitis, Crohn’s disease A – intersphincteric B – treansphincteric C – suprasphicteric D – extrasphincteric treatment Adequately drain: cruciate incision closed to anal verge Incision via intersphincteric groove in interphincteric abscess Supralevator: drainage via origin  rectal lumen, ischioanal fossa, abdominal wall Horseshoe abscess: Hanley’s or modified Hanley’s Fistulotomy – used in simple interphincteric and low transphincteric Fistulectomy – higher incontinence than fistulotomy LIFT – used in high transphincteric Seton – complex fistula, high trans and suprasphincteric
  27. 27. Rectal Prolapse  Signs & symptoms:  Obstructive defecation syndrome  Incontinence  constipation  Theory:  Sliding hernia  Rectal intussussceptioin
  28. 28. Rectal Prolapse  Pathophysiology  Deep CDS  Redundant sigmoid  Diastasis of levator ani  pelvic floor descent  Patulous anal sphincter  Loss of rectosacral attachment
  29. 29. Rectal Prolapse: Treatment  Thiersch procedure: only temporary  Perineal: used in high risk patient  Altemeire = perineal rectosigmoidectomy with levator plication  Delorme = sleeve rectal mucosal resection  Abdominal: lower recurrence rate  Frykman-Goldberg = sigmoidectomy with rectopexy

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