Lower GI Surgery for Finals - PowerPoint Presentation

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Lower GI Surgery for Finals

Alasdair Scott BSc MBBS MRCS PhD

Clinical Lecturer and Colorectal Surgical Trainee

as703@ic.ac.uk

28/11/2019

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Contents

Malignant

Colorectal cancer

Anal cancer

Benign

Perianal disease

Inflammatory bowel disease

Emergency

Diverticular disease

Bowel obstruction

Bowel ischaemia

Lower GI bleeding

Slide3

Malignant Conditions

Slide4

Colorectal Ca - Epidemiology

All cancers

Colorectal cancer

<10%

>90%

Slide5

Colorectal Ca - Pathophysiology

Adenoma

Invasive carcinoma

Slide6

Colorectal Ca - Risk Factors

Male sex, ↑ age

Family history

Inflammatory bowel disease

Genetic syndromes

FAP

HNPCC

Slide7

Colorectal Ca - Pathology

95% adenocarcinoma

Metastases

Liver

Lung

Peritoneal

Slide8

Colorectal Ca - Presentation

Elective

Emergency

Slide9

Colorectal Ca - Investigation

Diagnosis

Colonoscopy + biopsy

CT

Pneumocolon

Frail

Unable to tolerate bowel preparation

Staging

CT Chest, abdomen and pelvis

MRI for rectal cancer

Surveillance

CEA

CT +/- PET

Endoscopy

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Colorectal Ca - Treatment: MDT

Patient

Cancer nurse specialist

Stoma nurse

Surgeon

Radiology

Pathology

Oncology

Gastro-enterology

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Colorectal Ca - Treatment: Resections

Right hemicolectomy / extended right

Sigmoid colectomy

Anterior Resection / Total

mesorectal

excision (TME)

Abdominoperineal resection

Anatomy

Tumour

Caecum to splenic flexure

Sigmoid colon

Rectum

Low rectum

Anastomosis

Ileo-colic

Colo-rectal

Colo-rectal, or

Colo-anal

NA

Incision (if open)

Midline, or

Right transverse

Midline

Midline

Midline and perineal (no anus)

Stoma

No

Temporary loop ileostomy (unusual)

Temporary loop ileostomy (common)

Permanent end colostomy

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Colorectal Ca - Treatment: Chemo / Radio / Biologics

Chemo- / radio-therapy

prior

to surgery

Aim is to down-stage the

tumour

prior to surgery and lower risk of local recurrence

Only routinely used in locally advanced rectal cancer

Chemotherapy after surgery

Aim is to lower the risk of local recurrence and distant disease and prolong overall survival.Used for stage II/III colon or rectal cancer

For unresectable / incurable disease (stage 4)

Aim to prolong survivalNeo-Adjuvant Therapy

Adjuvant Therapy

Radiotherapy

Chemotherapy

Chemotherapy

Surgery

Palliative Therapy

Chemotherapy

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Colorectal Cancer - Summary

Epidemiology

4

th

commonest cancer

Lifetime UK risk: 1 in 15 males and 1 in 18 females

Peak incidence 85-89 years

>90% cases diagnosed in over 50sPathophysiologyAdenomas  carcinomas

Mounting genetic changesRisk FactorsAge

Male sexIBDFamily historyGenetic syndromes: FAP, HNPCCObesity

↑ animal fat / protein and ↓ fibre

Pathology

95% adenocarcinoma

~30% rectum

~30% sigmoid

~20% caecum / ascending

Metastases

Liver

Lung

Peritoneum

Presentation

Anorectal mass

Anorectal bleeding

Change in bowel habit

Weight loss

Anaemia

Abdominal pain

Large bowel obstruction

Investigation

Diagnosis

Colonoscopy + biopsy

CT

pneumocolon

Staging

CT abdomen and chest

MRI (rectum)

Surveillance

CEA

CT +/- PET

Treatment

Within the LGI MDT

Surgery

Resection

Diversion

Chemo- / radio-therapy

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Anal Cancer

HPV: esp. 16, 18, 31 and 33

Anal mass

Inguinal lymph nodes

Chemoradiotherapy

Squamous cell cancer

Slide15

Anal Cancer - Summary

Epidemiology

Relatively rare: 2/100 000 incidence

Pathophysiology

Squamous intraepithelial lesion (SIL)

LSIL: low-grade

HSIL high-grade

LSIL  HSIL  SCC

But, most LSIL and HSIL will not progress to SCCRisk Factors

HPV: esp. 16, 18, 31 and 33HIVMSMSmokingAge

Pathology

Nearly all variants of squamous cell carcinomas

Lymphatic drainage

Above dentate

 internal iliac nodes

Below dentate  inguinal nodes

Presentation

Anal mass

Pruritis anal

Anal bleeding

Incontinence

Fistula-in-

ano

Investigation

Diagnosis

EUA + Biopsy

Staging

CT abdomen and chest

CT PET

MRI

Treatment

Within the LGI MDT

Chemoradiotherapy

Surgery (APR)

Rare

For recurrent or non-responsive disease

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Benign Conditions

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Haemorrhoids

Painless PR bleeding

Pain if prolapsed and thrombosed

Prolapsed

haemorrhoids

Perianal

haematoma

(or external

haemorrhoid

)

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Skin tags, not haemorrhoids

!

Slide19

Fissure-in-ano

Painful

defaecation

associated with bright red bleeding

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Fistula-in-ano

Park’s Classification

Seton

Perianal abscess

“Abnormal connection between two epithelial surfaces.”

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Pilonidal Disease

Pilonidal sinus

Pilonidal abscess

“Blind-ending tract that opens onto an epithelial surface.”

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Rectal Prolapse

Elderly females with weak pelvic floor

Usually assoc. with incontinence

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Perianal Conditions - Summary

Condition

Presentation

Key Facts

Management

Haemorrhoids

Painless, bright red PR bleeding

Prolapse from the anus

Painful thrombosis

Associated with constipation and strainingConservative

Banding or injectionsSurgical: excision or stitchingFissure-in-anoPainful, bright red PR bleeding

May be associated with skin tagAssociated with constipation

Usually posterior @ 6 o’clockLaxativesGTN or diltiazem ointmentEUA + Botox injection(Rare: sphincterotomy or flap)

Fistula-in-

ano

Perianal discharge

Perianal abscess

Follow

Goodsall’s

Rule

May be assoc. with Crohn’s disease

May investigate with MRI

EUA +/- fistulotomy +/- seton

I+D for abscesses

Pilonidal disease

Discharge from natal cleft

Pilonidal infection or abscess

Presumed foreign body reaction from hair working it’s way beneath the skin.

Surgical excision

I+D for abscesses

Rectal prolapse

Full thickness, circumferential prolapse of rectum

Incontinence

Bright red PR bleeding

Usually elderly females with weak pelvic floor.

Often associated with incontinence

Conservative

Surgery: abdominal and perineal approaches

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Inflammatory bowel disease: presentation

Typically young patient: usually 20-30s

Males slightly more common than females

Diarrhoea

- may be bloody or contain mucous

Abdominal pain

Weight loss

Perianal disease - Crohn’s

Obstruction - Crohn’sMalignancy

Extra-abdominal features: e.g. skin, eyes, joints

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Inflammatory bowel disease: investigation

Diarrhoea

and abdominal pain

Faecal

calprotectin

FC Low

Treat as IBS

FC High

Persistent symptoms

Colonoscopy

Red flags:

Age >=60

Weight loss

Anorectal bleeding

Nocturnal symptoms

Fever

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Inflammatory bowel disease: medical management

Induce remission

Maintain remission

Steroids: e.g. prednisolone, budesonide

5-ASAs

Biologics: e.g. infliximab, adalimumab

Immune modulator

UC:

ciclosporine

CD: methotrexate, azathioprine

Slide27

Inflammatory bowel disease: surgical management

Emergency

UC

Elective

Indications

Failure of medical management

Massive bleeding

Perforation

Toxic megacolon

Procedures

Subtotal colectomy

Indications

Failure of medical management

Carcinoma or high-grade dysplasia

Procedures

Curative intent

Proctocolectomy and either end ileostomy or pouch

Total colectomy and ileorectal anastomosis

CD

Indications

Failure of medical management

Massive bleeding

Perforation

Stricture

 obstruction

Procedures

Limited resection

Stricturoplasty

Diverting ileostomy

Indications

Failure of medical management

Stricture

Perianal disease

Carcinoma or high-grade dysplasia

Procedures

Never curative

Limited resection or

stricturoplasty

Perianal procedures

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Procedures for UC: subtotal colectomy

Remove diseased colon

Leave rectosigmoid stump

End ileostomy

+/- “mucus fistula” as end-colostomy

Usually a temporizing procedure

Follow by either:

Completion proctectomy

Proctectomy and formation of ileal pouch

Ileo-rectal anastomosis

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Procedures for UC: proctocolectomy

Remove colon + rectum and either:

Remove anus, leaving permanent end ileostomy

Leave anus and create an ileal pouch

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Procedures for UC: ileal pouch anal anastomosis

Performed to restore continence after a proctectomy

Typically a “J Pouch”

Usually “covered” with a temporary defunctioning loop ileostomy because of high risk of anastomotic leak

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IBD: Summary

Epidemiology

Typical onset in 20-30s but can occur at any age

Affects M and F equally

Pathophysiology

Autoimmune-mediated

UC: TH2

CD: TH1Interaction between microbial, immune, genetic and environmental factors

Risk FactorsSmoking↑ risk of CDProtective in UC

Family history

Pathology

Presentation

Diarrhoea

+/- blood/mucus

Weight loss

Abdominal pain

Perianal disease (CD)

Obstruction (CD)

Malignancy

Extra-abdominal features

Skin: pyoderma gangrenosum

Eyes: uveitis

Joints:

enteropathic

arthritis

Investigation

Faecal

calprotectin

Ileocolonoscopy

Treatment

Medical

Induce and maintain remission

Steroids

5-ASA

Biologics

Immune modulators

Surgical

Can be curative in UC but not CD

Management of complications or failure of medical management

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Diverticular disease: presentation

Outpouchings of mucosa through colonic muscular wall - ”false diverticulum”

Diverticulosis:

presence of

diverticulae

, usually asymptomatic

Diverticular disease:

diverticulae

with symptoms

Pain:

usually LIF, relieved by defaecation, diarrhoeaDiverticulitis: LIF pain, fever, diarrhoea

+/- blood, ↑ CRP/WCC Perforation: abscess or acutely unwell with peritonitisBleeding: usually painless, bright or dark redStricture: can cause large bowel obstruction

Fistulae: can fistulate into bladder or vagina

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Per

forated diverticulitis classified by the Hinchey Classification system

Localised

, para-colic abscess

Pelvic abscess

Purulent peritonitis

Faeculent

peritonitisDiverticular disease: classification

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Diverticular disease: management

Diverticulitis

Typically managed with antibiotics (PO or IV) but no evidence for benefit in uncomplicated diverticulitis.

Occasionally resection is offered for debilitating symptoms

Diverticular abscess

Antibiotics

Drainage by interventional radiology

Perforation with peritonitis

Laparoscopic washout may be suitable for mild purulent contamination

Hartmann’s procedure

Bleeding

Usually managed conservativelyOccasionally embolisedResection rare

Stricture or fistulae

Sigmoid resection

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Diverticular disease: Hartmann’s Procedure

“Emergency sigmoid colectomy in which the proximal colon is exteriorized as an end-colostomy and the rectal stump is over-sewn and left in situ.”

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Diverticular disease: summary

Epidemiology

Common

Incidence increases with age: 10% at 40yrs and 80% at 80yrs

Pathophysiology

Unclear

? High luminal pressures

 herniation of mucosa at sites of weakness where arteriole enters bowel wall.

Only 10% get symptomsRisk FactorsAge

? ↑ animal fat / protein and ↓ fibreObesity  ↑ risk of inflammation or bleeding

Presentation

Diverticulitis

Abscess

Peritonitis

LGI bleeding

LBO

Fistula

Investigation

CT abdomen

Endoscopy /

Treatment

Diverticulitis:

Abx

Occasionally resection if recurrent attacks

Abscess:

drainage

Peritonitis:

Hartmann’s

Bleed:

conservative or IR embolisation

LBO:

resection

Fistula:

resection

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Bowel obstruction: presentation

Abdominal distension

Abdominal pain

Absolute constipation

Vomiting

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Bowel obstruction: radiology

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Bowel obstruction: radiology

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Bowel obstruction: radiology

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Bowel obstruction: radiology

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Bowel obstruction: radiology

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Bowel obstruction: management

Resuscitation: drip and suck

NBM

Imaging: CT abdomen and pelvis

Small bowel obstruction

Conservative

Adhesional

obstruction without suspicion of bowel ischaemia

May try

gastrograffin

per NG

Surgical

Suspected bowel compromise

Causes other than adhesions: e.g. hernia

Failure of medical management

Large bowel obstruction

No place for conservative management

Interventional

May occasionally stent benign or malignant strictures

Flatus tube for sigmoid volvulus

Surgical

Typically laparotomy + resection

Occasionally diverting loop colostomy

May occasionally stent benign or malignant strictures

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Bowel obstruction: summary

Classification

Simple

Closed loop: 2 obstructing points

Band

IC valve

Strangulated

Common causesSBOAdhesions

HerniaLBODiverticular strictureColorectal cancer

Volvulus

Other causes

Non-mechanical

Ileus

Pseudo-obstruction

Mechanical

Extra-luminal

Mural

Luminal

Presentation

Abdominal pain

Abdominal distension

Absolute constipation

Vomiting

Investigation

AXR

CT

Lactate

Management

Drip and suck

NBM

Conservative

Adhesional

SBO

Interventional

E.g. stenting

Surgical

Slide45

Bowel ischaemia

Presentation

Severe abdominal pain

Shock

Acute Mesenteric Ischaemia

Nearly always small bowel

Investigation

↑ lactate and WCC/CRP

Triple phase CT: pre-contrast, arterial and venous phases

Management

ResuscitationLaparotomy + SB resection

CauseThrombo-embolic

Veno-occlusiveHypovolaemic

Ischaemic

Colitis

Large bowel, usually splenic flexure

Cause

Chronic thrombus

Presentation

Moderate left-sided abdominal pain

Diarrhoea

+/- blood

Investigation

WCC/CRP

CT abdomen

Management

Conservative: Abx, IV fluid

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Bowel ischaemia: radiology

Slide47

Lower GI Bleeding

Causes

Common and important

Perianal:

haemorrhoids

, fissures

Colorectal cancer

DiverticularIBD

Brisk upper GIInfectionIschaemia

AngiodysplasiaTrauma

Slide48

Stomas

Classification

Anatomy

Ileostomy

Colostomy

Urostomy

Jejunostomy

Gastrostomy

Nephrostomy

TypeEndLoop

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Stomas: complications

Complications

 

Early

Haemorrhage

Ischaemia

High output (can → fluid and electrolyte disturbance)

Stoma retractionParastomal abscess

 DelayedParastomal hernia

Bowel obstruction: 2O to adhesions or herniaDermatitis (esp. ileostomy)

Stoma prolapseStenosis or stricturePsychosexual dysfunction

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Stomas: summary

Assessment

S

ite

S

tool type: solid, small bowel content, urine

S

poutStomas: how many openings?Stateof surrounding skinof intestinal mucosa

Scars

Ileostomy

Colostomy

Watery stool

Solid stool

RIF

LIF

Spouted

No spout

“Artificial union between a hollow viscus and the skin”

2. Indications

 

Output

Diversion

of bowel or ureters

Distal anastomosis: e.g. anterior resection

Discontinuity

e.g. Hartmann’s or AP resection

e.g. urinary diversion post cystectomy

Distal disease: e.g. severe Crohn’s disease

Decompression

due to distal obstruction

 

Input

Feeding:

e.g. gastrostomy / jejunostomy

Lavage:

e.g. appendicostomy

3. Complications

 

Early

Haemorrhage

Ischaemia

High output

Stoma retraction

Parastomal abscess

 

Delayed

Parastomal hernia

Bowel obstruction

Dermatitis (esp. ileostomy)

Stoma prolapse

Stenosis or stricture

Psychosexual dysfunction

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The Game Plan:

What do examiners want?

Key cases in Surgery Finals

What to look out for on examination

How to talk the talkHow to prepare