Colorectal-anus short note by S.

Wichien (SNG KKU)

Anatomy Anorectal Landmark

Histology -rectum 12-15 cm
-mucosa (lower 4-8 cm mid 8-12 cm upper 12-16 cm)
-submucosa -sx anal canal 2-4 cm
-inner cir int anal sphinc -3 valve of Houston
-outer long 3 tenia coli Peritoneal reflection
-serosa -upper ant+lateral
-middle ant pouch of douglas
Embryology -lower no peritoneum but have fascia
-primitive gut derived from endoderm :post waldeyer fascia
Midgut :ant denovillier fascia
-small intestine, asc.colon, prox T.colon :lateral ligament
-SMA Endopelvic fascia
Hindgut -visceral layer
-distal T.colon, des colon, rectum, prox.anus -parietal fascia presacral fascia
-IMA Dentate/pectinate line
Distal anus -longitudinal fold column of Morgagni
-ectoderm -anal crypt
-int pudendal A -above dentate columnar
-dentate line use to divide -dentate transitional zone
-below dentate squamous
Colon Landmark Sphincter
-3-5 feets Internal sphincter
-rectosigmoid=sacral promontary -smooth m
-caecum diameter 7.5-8.5 cm -sym & parasym
-sigmoid External sphincter
:narrowest most to obstruct -3 group
:extremely mobile most vulvulus -subcu, superficial, deep group(puborectalis)
:diverticulitis -ext sphinc = inf rectal br of int pudendal n.
-marginal A of Drummond Levator ani
-arch of Rioland -puborectalis
SMA iliococcygeus
-ileocolic terminal ilium, asc.colon pubococcygeus
-rt colic a asc.colon -int pudendal
-middle colic T.colon Artery
IMA -sup rectum = IMA
-lt colic a des.colon -mid rectum = int illiac
-sigmoid br sigmoid colon -inf rectum = int pudendal int iliac
-sup rectal prox rectum Lymphatic
Watershed area -upper/middle rectum = inf mesen LN
1.Griffith point splenic flexor -lower rectum = inf mesen LN, int iliac LN
2.Sudak point -anal canal
Lymp drainage :prox dentate = inf mesen, int iliac LN
-network in m.mucosa :distal dentate = inguinal LN
Nerve Nerve plexus
-sympathetic (inhi) T6-12,L1-3 -sym (L1-3) hypogatric plexus
-parasym (stimu) vagus n, sacral n (S2-4) -parasym (S2-4)

Symp inj retrograde ejacu & contract BD

Parasymp inj ED & acute urinary retention
 Colorectal-anus short note by S.Wichien (SNG KKU)

Physiology S+S
Fluid/elyte 1.Pain
-90% water in ileum :absorb in colon -abdominal pain
-1000-2000cc/d -pelvic pain
-Na absorb via Na-K ATPase -anorectal pain
-can absorb Na 400 mEq/d :proctalgia fugax-levator spasm
-K absorb by passive diffusion
-Cl absorb via Cl-HCO3 exchange 2.LGIB
-protein,urea --bact--ammonia -NG tube r/o UGIB
-amonia to liver due to intraluminal pH -proctoscope r/o hemorrhoid
-dec bact/pH>>dec absorb ammonia -rbc scan detect bleeding 0.1 cc/hr
(lactulose administration ) If +ve
Short chain fatty a. :angiography to localized bleeding
-acetate,butyrate,propionate :vasopressin iv
-produce by bact ferment of carbo :angioembolization
-energy for colonic mucosa,transport -if stable pt,rapid bowel preparation
-lack of dietary,diversion fecal stream (4-6hr) to allow colonoscopy
result in m.atrophy=Diversion colitis -colonoscopy identify cause bleeding,
Microflora cautery or inject epi may control bl.
-bacteroides=most common anaerobe -if persist bleeding = colectomy
-e.coli=most common aerobe :segmental resection
-breakdown carbo,prot
-metabolism of bili,bile a,estro,chol 3.constipation
-produce vit k 4.diarrhea/IBS
-suppress patho organism--c.difficile 5.incontinence
-gas=n2,o2,co2,h2,methane -neurogenic
(bact=h2,methane) -anatomic
Motility :procidentia
-not cyclic motor activity character of :overflow inconti 2nd to impaction
migratory motor complex in small b. :trauma >>vg.delivery,sx
-intermittent contraction
low amplitude
-short duration contraction
-burst,move content ante/retrograde
-delay colonic transit
:absorp water,elyte
Hi amplitude
-mass movement
Defecation
-colonic mass movement
-inc intraabdo/rectal p.
-relax pelvic floor
-rectum distend--reflex relax sphincter
:rectoanal inhibitory reflex
:no reflex Hirschprung disease
-sampling reflex
:distinguish solid stool from liquid/gas
-no defecate accommadation reflex
Continence
-puborectalis--sling around distal R.
-rectal wall compliance
-ext/int sphincter
-n=br of int pudendal n
 Colorectal-anus short note by S.Wichien (SNG KKU)

Lower GI bleeding

Constipation Ix
Rome III criteria Colonic fxn
>=2/6, 3 mo 1.colonic transit time
Onset at least 6 mo -20 markers
No IBS criteria -dx if d5 > 5 marker
-straining 2.colonic manometry
-lumpy/hard stool 3.colonic scintigraphy
-incomplete evacuation
-anorectal obstruct sensation Anorectal fxn
-manual evacuation 1.anorectal manometry (gold std)
-defecate <3/week -no RAIR Hirschprung disease
2.balloon expulsion test
Approach -should < 5min
1.BE/colonoscope 3.defecogram
-r/o mechanical obstruction -rectocele/enterocele
2.slow transit vs outlet obstruction -intussusception
-megarectum
-rectal prolapsed
4.pudendal n terminal motor latency
 Colorectal-anus short note by S.Wichien (SNG KKU)

Lab+imaging Sigmoidoscope
FOBT -60 cm in length
Advantage -see high as splenic flexor
-non invasive -enema is adequate for scope
-low cost Advantage
-good sens c repeat testing -bowel prep=enema only
Disadvantage -exam most risk(sigmoid)
-low spec Disadvantage
-colonoscopy require for test+ve -invasive
-risk perforate
BE -miss proximal lesion
Advantage -colonoscopy if polyps identify
-entire colon
-good sene in polyps >1cm Colonoscopy
Disadvantage -100-160 cm in length
-required bowel prep -require oral bower preparation
-less sens in <1cm -require sedation
-may miss lesion in sigmoid -electrocautery not in absence bowel
-colonoscopy if test +ve preparation=risk of explosion
Advantage
Endoanal/rectal ultrasound -entire colon
-dept of invasion in rectum -hi sens,spec
-normal = 5 layer Disadvantage
:mucosal surface,m.mucosa, -most invasive
submucosa,m.propia,perirectal fat -require sedation/bowel prep
-perirectal LN -risk perforate

CT CT colonography/
-extraluminal lesion virtual colonoscopy
-insensitive for detect intraluminal Advantage
-entire colon
Positron emission tomography -noninvasive
-PET -sens as colonoscopy
-tissue c high level of anaerobic Disadvantage
glycolysis(tumor) -require bowel prep
-F-fluorodeoxyglc(FDG) is tracer, -insen for small polyps
metabolism of it = positron emission -colonoscopy if test +ve
-as an adjunct to CT in staging -costly
-distinguish recurrent vs fibrosis
Pelvic floor ix
Anoscope Manometry
-anal c. -resting pressure = int sphincter
-8 cm in length (normal 40-80mmhg)
-rubber b.ligation,sclerotherapy -squeez pressure = ext sphincter
(max p-resting p)
Proctoscope (normal above resting pressure 2x)
-rectum,distal sigmoid
-25 cm in length Neurophysiologic testing
-assess pudendal n

Rectal evacuation study

-ballon expulsion test
-video defecography

Anal fissure
-tear in anoderm distal to dentate line
-related to trauma from passage hard
stool or prolong diarrhea
-cause spasm of int anal sphincter
:pain--spasm--dec bl.supply
:this cycle develop chronic fissure
-major in posterior midline
10-15% in ant middle
Sign/symptom
-tearing pain c defecation
-hematochezia:bl on toilet paper
-anal spasm lasting several hours
after bowel movement
-seen by gently separate buttock
-too tender on PR/proctoscope
Tx
Medical Tx--is effective in acute
but only 50-60% in chronic fissure
-bulk agent
-stool softener
-warm sitz baths
-2%lidocain jelly
-0.02%nitroglycerine ointment
:improve bl.flow
:but often severe headache
-ca channel blocks
:diltiazem,nifedipine
-newer agent
:arginine
:topical bethanechol (muscarinic ago)
-injection of botulinum toxin
:inhi Ach release from presynap
:cause temporary m.pararlsis
:alternative to sx sphincterotomy
Sx
-in chronic fissure that fail medical
lateral sphincterotomy
-procedure of choice
-divide 30% of internal sphincter fiber
-open or closed technique
-risk of incontinence (flatus)
Colorectal-anus short note by S.Wichien (SNG KKU)
Anorectal abscess
-Cryptoglandular infection
-infect of anal glands
-intersphincteric plane
-ducts traverse int sphincter into
crypts at level of dentate line
Space
-Perianal space
-Intersphincteric space
-Ischiorectal space
-Pelvic/supralevator space
Dx
-severe anal pain
-inc by walking,coughing,straining
-fever,uri retention
-life threatening abscess
Treatment
-drainage as soon as dx
-ATB alone ineffective
Perianal abscess
-cruciate skin and subcu incision
-no packing is necessary
-sitz baths in nextday
Ischorectal abscess
-diffuse swelling in ischorectal fossa
-incision in overlying skin
-both=horseshoe abscess
:drainage of deep postanal space
:often require counterincision over
one/both ischorectal space
Intersphincteric abscess
-difficult to dx
-few perianal signs
-pain deep and up inside anal area
-posterior internal sphincterotomy
Supralevator abscess
-uncommon,difficult to dx
-mimic intraabdo condition
-PR=indurated bulging mass
-identify origin of abscess prior to tx
-if 2nd to extension of intersphincteric,
should be drained through rectum
-if from ischorectal,should be drained
through ischorectal fossa
-if from intraabdo ds,should drain via
most direct route

Fistula in ano
-50%of drainage of anorectal abscess
-internal opening : infected crypt
-external opening: site of prior drain
-non-healing fistula should aware
:crohn disease,malignancy,radiation,
TB,actinomycosis,chlamydia
Diagnosis
-persist drainage from int/ext opening
-indurated tract is often palpable
Goodsall rules
-determine locate of internal opening
1.external opening anteriorly
-short-radial tract
-except this rule if >3cm--post midline
2.external opening posteriorly
-curve to post midline
Type
1.intersphincteric fistula
2.transphincteric fistula
3.suprasphincteric fistula
4.extrasphincteric fistula:rare
Complex fistula
-hi transphincteric
-suprasphincteric
-extrasphincteric
-ant fistula in female
-multiple tract
-recurrent fistula
-asso incontinence
-s/p XRT
-crohn dz/ AIDS
Colorectal-anus short note by S.Wichien (SNG KKU)
Treatment
-locate int/ext opening
-external opening usually visible
-injection of hydrogen peroxide or
dilute methylene blue may be helpful
1.Simple intersphincteric fistula
-fistulotomy/curettage
-wound healing by2nd intention
2.Transphincteric fistula
:depend on location in sphincter
<30% of sphincter
-sphincterotomy
-without signi risk of major incontine
>30% of sphincter
-initial placement of seton
3.Suprasphincteric fistula
-seton placement
4.extrasphincter fistula
-fistula outside sphinc--drain+open
-1°tract at level of dentate line
:may opened if present
-seton
Failure to heal
-require fecal diversion
-may from malignancy,crohn,radiate
-proctoscope assess rectal mucosa
-bx can r/o malignancy
Seton
-drain placed through fistula
-maintain drainage/induced fibrosis
Cutting seton
-suture or rubber band placed through
fistula and intermittent tightened
-tightening the seton results in fibrosis
and gradual division of sphincter
Noncutting seton
-soft plastic drain,often vv loop
-placed in to maintain drainage
-tract may be laid open with less risk
of incontinence because scarring
prevent retraction of sphincter

Hemorrhoids
-cushions of submucosa
-contain venule, arteriole, smooth m.
-3 hemorrhoidal cushion in
left lateral, right ant, right post
-fxn as continence mechanism
-complete closure of anal canal
External hemorrhoid
-located distal to dentate line (anoderm)
Thrombosed hemorrhoid
Tx-24-72 hr sx, >72 hr supportive Tx
Skin tags
-often confused c symp hemorrhoid
-redundant fibrotic skin at anal verge
-residual of thrombosed ext hemorr
-Tx-only indicated for symptom relief
Internal hemorrhoid
-proximal to dentate line
-covered by insensate anorectal mucosa
-rarely pain, unless thrombosis/necrosis
-may prolapsed, bleeding
Grading
1st =may prolapse on straining
2nd=reduced spontaneous
3rd=require manaul reduction
4th=can't reduce,risk for strangulation
Portal HT pt
-Hemorrhoid = normal population
-risk bleeding > normal population
Hemorrhoid Tx
Medical
-bleeding 1st, 2nd degree
-diet fiber, stool softener, water
-avoid straining
Rubber band ligation
-persist bleeding 1st, 2nd, 3rd
-pulled mucosa 1-2 cm proximal to dentate
-1, 2 quadrants are banded
-severe pain--placed distal to dentate
c/p
1.urinary retention
-1% of pt -ligate int sphincter
2.infection
-necrotizing infection
-rare but life threatening
-severe pain, fever, chill, urine retention
3.bleeding
-may 7-10 after rubber band
-usually self limit
-may require suture ligation
Colorectal-anus short note by S.Wichien (SNG KKU)
Infared photocoagulation
-small 1st,2nd degree
-apply to apex of each hemorrhoid
-coag underlying plexus
-all 3 quadrant may be tx in same visit
-large,prolapsed not effective
Sclerotherapy
-sclerosing agent
:5-phenol in olive oil
:sodium morrhuate
:quinine urea
-inject bleeding hemorrhoid
-1st,2nd and some 3rd
-1-3 ml of agent inject to submucosa
Excision of thrombosed Ext Hemorrhoid
-24-72 hr
-elliptical excision under LA
-usually loculated--I$D--ineffective
-72hr--begin resorb--not excision
Hemorrhoidectomy
1.Closed submu hemorrhoidectomy
Park or Ferguson
-prone/lithotomy -fansler anoscope
-elliptical incision distal to anal verge
and extended proximally
-ligated apex of hemorrhoid plexus
-resect hemorrhoid tissue
-closure c running absorb suture
-must identify fiber of int sphincter
-avoid resect large area--stenosis
2.Open hemorrhoidectomy
Milligan and Morgan
-as above but wound are left open
-allow to heal by 2nd intention
3.Whitehead hemorrhoidectomy
-circumferential excision of H
-proximal to dentate line
-most don't use this method
risk of ectropion (whitehead deform)
4.Stapled hemorrhoidectomy
-alternative sx
-remove short circum segment of
rectal mucosa proximal to dentate
line using circula staple
-for large,bleeding int hemorrhoid
-not in ext/combined hemorrhoid

Diverticular disease
-acquired (major) false diverticula
-congenital true diverticula
-75% asymptom, 25% symptom
-75%diverticulitis, 25%bleeding
Diverticulosis
-diverticula without inflam
-sigmoid=most common
-lack of dietary fiber
-most=asymptom
Diverticulitis
-10-25% of diverticulosis
-lt side abdo.pain,leukocytosis,fever
1.uncomplicated diverticulitis
-LLQ pain
-CT:pericolic soft tissue stranding,
colonic wall thickening,phlegmon
-Rx=ATB
-most=recovery without sx in 7-10 d
-sigmoidoscope 4-6 wk after recovery r/o ca
Sx--elective sx
-sigmoid colectomy c 1°anas
(procedure of choice)
-resect extend to rectum
-recurrence if retain sigmoid colon
Elective Sx I/C
1.>=2 episode
2.1 episode+young pt
3.1 episode+complicated diverticulitis
4.1episode+immunocompromise
2.complicated diverticulitis
Hinchey staging system
1-colonic inflam c pericolic abscess
2-retroperitoneal or pelvis abscess
3-purulent peritonitis
4-fecal peritonitis
Rx
-abscess<2cm--iv ATB
-larger--CT guide percu.drain--best
Emergency laparotomy
-can't percu.drain
-free air / peritonitis
Stage1,2
-sigmoid-colectomy c 1°anas
(one stage operation)
Stage3,4
-sigmoid-colectomy c end colostomy c
Hartman pouch (most common)
Colorectal-anus short note by S.Wichien (SNG KKU)
Others
-sigmoid-colectomy c 1°anas +/-
on table lavage c prox.diversion
(loop ileostomy)
Obstruction
-67% of diverticulitis
-10% complete obstruction
-sigmoid colectomy c end colostomy
Fistula
-5%of complete diverticulitis
-1st--colovesical--most common
2nd--colovg,coloenteric
Rare--colocutaneous
-best Ix=CT with contrast
2 key point
1.defined anatomy of fistula
2.exclude other dx
-DDx--malignancy,crohn,RTX induce
-barium enema, CT, colonoscopy
-Hx RTx--1st--should r/o recurrent ca
Rx
-resection of affected segment
(usually 1°repair) and simple repair
of involved organ
Hemorrhage
-erosion of peridiverticula arteriole
-may massive
-elderly
-80% spon.stop
Rx
-colonoscopy+epi injection/cautery
-angiography--dx+therapeutic
-laparotomy--segmental colectomy
Giant colonic diverticula
->4cm
-rare
-antimesen of sigmoid colon
-pain,nausea,constipation
-Ix--BE
-c/p--perforate,obstruct,volvulus
Tx
-should sx despite asymptom
-symptom resection
-asymptom diverticulectomy
 Colorectal-anus short note by S.Wichien (SNG KKU)

Diverticular disease (cont) Pilonidal disease

Rt side diverticula -hair containing sinus/abscess
-cecum, asc.colon -in intergluteal cleft
-young pt -unknown etiology
-most--asymptomatic -cleft suct hair into midline when sit
-ddx=appendicitis -ingrown hair=infect
-dx in operating room Tx
Pre op Dx acute
-good clinical ATB iv -incised and drain
-not good pt rt hemicolectomy ¤midline w--heal poorly
Intraop Dx ¤incision--lateral to gluteal cleft
-complicated rt hemicolectomy chronic
-uncomplicated appendectomy, ATB iv -unroof tract
-curetting base
Pruritis ani -marsupializing wound
Sx correctable -free of hair
-prolapsed hemorrhoid Complex/recurrent sinus
-ectropion -more extensive resection
-fissure -Z plasty/advancement flap/
-fistula Rotational flap
-neoplasm
Infection STD
-fungus=candida,monilia Bacteria : proctitis
-parasite=enterobius,scabies,louse -n.gonorrhea=most common
-bact -c.trachomatis
corynebac.minutissimum(erythrasma) -t.pallidum=chancre
treponema pallidum(syphylis) -h.ducreyi
-virus=HPV :chancroid
Noninfectious :inguinal lymphadenopathy
-seborrhea -donovania granulomatis
-psoriasis :granuloma inguinale
-contact dermatitis :red mass on perineum
-jx Parasite
-DM -e.histolytica
:ulcer in GI mucosa
Hidradenitis suppurative -giardia lamblia
-infect of cuta.apocrine sweat gl. Viral
-infect gl.rupture>form subcu.sinus T HIV
-mimic complex fistula HSV T.2
-stop at anal verge, because HPV
no apocrine gl.in anal canal -anogenital wart,condy.accuminata
Tx -asso AIN,sq.cell ca
-I&D in acute abscess -HPV T.6,11--no ca
-unroof fistula,debride granulation -HPV T.16,18--ca
Tx
-topical podophyllin--small lesion
-imiquimod (Aldara)--severe lesion
-excision in large lesion
+ can r/o dysplasia
 Colorectal-anus short note by S.Wichien (SNG KKU)

Megacolon Solitary rectal ulcer syndrome

-chronic dilate,elongate,hypertrophy -asso internal intussusception
-congenital vs acquire -pain,bleeding,mucus d/c,obstruc
-asso chronic Mechanical or fxn obstr -one or more ulcer in distal rectum
-exclude correctable mecha.obstr -ant.wall 4-12 cm from AV
Congen.
-Hirschprung dz colitis cystica profunda
-no GG cell in distal colon -nodule/mass in similar location
-failure of relaxation -mucosal gland in submucosa
-fxn obstruction
-resect aganglion segment Ix
-can later in childhood -bx r/o malignancy
:ultrashort-srgment hirschprung dz -colonoscopy /BE
Acquired -defecogram r/o rectal intussusception
Infection Tx
-T.cruzi (chagas dz) Nonsx
:destroy GG cell -hi-fiber diet
:megacolon/eso -defecation to avoid straining
chronic constipation -laxative/enema
-from slow transit Sx
-med--anti cholinergic -as prolapsed
-neurologic--paraplegia -in symptomatic pt,fail med
Tx
-diverting ileostomy or
subtotal colectomy c ileorectal anas Typhlitis
-neutropenic enterocolitis
-life-threatening
Colonic pseudo-obstruction -abdo.pain/distend,fever,
-Ogilvie syndrome diarrhea()bloody),n/v
-fxn disorder -neutropenia
-absent mech.obstruction -difficult dx due to lack inflam rxn
-massive colon dilate -CT
(esp.rt and transverse colon) :dilate cecum c pericolic stranding
-common in hospitalized pt :normal not r/o ds
-narcotic,anticholi,bed rest comorbid -perianal pain
-autonomic dysfxn Rx
-adynamic ileus -bowel rest
-ATB
Step Tx -parenteral nutrition
1.conservative Tx NG, rectal tube, elyte -granulocyte infusion
2.Neostigmine (Achesterase inh) -perforate >> sx
-s/e=bradycardia
-not in CVS ds
3.colonoscopic decompression
4.Sx
-gangrene resection
-good caecum cecostomy
 Colorectal-anus short note by S.Wichien (SNG KKU)

Rectal prolapse Volvulus

-circum,full thickness protusion 1.sigmoid (90%)
-1st degree/complete/procidentia 2.caecum (<20%)
-internal prolapse=intuss 3.T.colon (3%)
-female:male=6:1
-women:inc with age 1.Sigmoid volvulus
-men:unrelated with age -volvulus belt africa, india
-M > F
Mucosal prolapse -40-50 yr
-partial thickness protusion Etiology
-often asso hemorrhoid -elongated /mobile sigmoid colon
Tx--banding/hemorrhoidectomy -narrow mesenteric attachment
Gangrene part
Clinical -neck of volvulus
-tenesmus -in closed loop
-tissue protuding -proximal or distal of neck
-incomplete evacuation Perforate site
-mucus d/c,leakage -caecum
-fxn complaint--incontinence/constipa Clinical
1.acute fulminant type
Ix 2.subacute progressive type
-colonic transit study Signs
-anorectal manometry -Von Walhl sign mass of distended loop
-colonoscope/BE--exclude ca/diverti -emptiness of LLQ
X-ray
Tx -bent inner tube/ coffee bean/ omega sign
1.Abdominal approach -Northern exposure sign (apex above TC)
1.Moschowitz repair Limited BE
-reduction of perineal hernia and -bird beak (pathognomonic)
closure of cul-de-sac CT
-whirl sign
2.fixation of rectum Endoscope
2.1 Ripsten and Well rectoplexy) -whirl sign
-with prosthetic sling Tx
2.2 suture rectoplexy 1.endoscopic decompression
-rigid or flexible sigmoidoscope
3.resection rectoplexy (Fryman Goldberg) -C/I peritonitis, suspect gangrene bowel
-resection of redundant sigmoid colon -recurrent rate 40-70%
may combine c rectal fixation 2. 1+endoscopic sigmoidoplexy
-T fasteners sigmoidoplexy
2.Peritoneal approach 3.Sx
1.Delorme procedure Emergency
-mucosal resection+suture plication -Hartman procedure (safest operation)
2.Perineal rectosigmoidectomy or Elective
Altemeier procedure -sigmoidectomy
3.2+levatoplasty -sigmoidoplexy
4.Thiersch operation -mesosigmoidoplasty
-circular thightening
 Colorectal-anus short note by S.Wichien (SNG KKU)

Volvulus (cont) 4.ileosigmoid knotting

2.cecal volvulus -double closed loop obstruction
-F > m Etiology
-elderly -hypermobile smb
Etiology -redundant sigmoid
-hypermobile cecum Type
-inadequate rt colon fixation 1-ileum around sigmoid
Type 2-sigmoid around colon
1-axial torsion type 3-ileocecal segment around sigmoid
2-loop type 4-undetermined
3-cecal buscule type CT
Clinical -whirl sign
-acute smb obstruction Tx
-chronic recurrent abdo pain -sigmoid Hartman
X ray -ileum resection + 1°anastomosis
-cecal dilatation
-absence gas at distal colon
-smb obstruction
BE
-bird beak appearance
-not recommend perforate
CT
-Ix of choice
-whirl sign
Tx
1.endoscopic decompression
-not recommend most can't
2.Sx
-cecostomy
-detorsion+cecopexy hi recurrence
-ileocecectomy or RHC c 1°ileocolic anas

3.Transverse colon volvulus

-rare
-F > M
-asso sigmoid volvulus & chilaiditi synd
Etiology
-redundant T.colon
-mesenterium commune (not fix asc/des C)
CT
-whirl sign
Tx
-extended RHC + 1ºanastomosis
 Colorectal-anus short note by S.Wichien (SNG KKU)

Rectovaginal fistula RV fistula Tx

-connect btw vagina and rectum/anal canal OB inj
-proximal to dentate line -50%heal spon--wait 3-6mo

1.Low Cryptogl abscess

-rectum--close to dentate line -drainage allow spon closure
-vagina--fourchette
cause low+mid rectovaginal fistula
-common caused by OB inj -endorectal advancement flap (best Tx)
-trauma from FB -healthy mucosa,submu,cir muscle
2.Middle
-vagina--between fourchette and cx if sphincter inj
cause -overlapping sphincteroplasty
-after sx resect of midrectal neoplasm -fecal diversion =rare
-radiation inj
-more severe OB inj hi fistula
-extension of undrain abscess -best tx via trans-abdo pproach
3.High -bowel is resected
-vagina--near cervix -closed hole in Vg
cause -omentum interposed
-operative
-radiation inj Crohn
-adequate drain of perianal sepsis
complicated diverticulitis -advancement flap may performed if
-may cause colovaginal fistula spare from active dz
crohn dz
-cause RV fistula all level Radiation
-colovaginal, enterovaginal fistula -can't flap
-bx--r/o ca
Dx
-pass flatus from vagina to
-pass solid stool from vg
-some degree of fecal incontinence
-contaminate result in vaginitis
-anoscope/vaginal speculum may dx
-BE or vaginogram may identify
-methylene blue into rectum
while tampon in vagina may dx
 Colorectal-anus short note by S.Wichien (SNG KKU)

Ischemic colitis Infectious colitis

-intes colitis--most com=colon Pseudomembranous colitis
:splenic flexure -c.difficile
-from low flow/small vv occlusion -nosocromial diarrhea
-rarely asso major a/v occlusion -give ATB=deplete normal flora
-splenic flexure=most site :clindamycin
-rectum=spare(rich collateral br.) -2 toxins
:toxin A-enterotoxin
Risk factors :toxin B-cytotoxin
-vascular dz -ulcer plaque,pseudomembranous
-DM Ix
-vasculitis -stool c/s
-hypoT -immunoassay for toxins
-ligate IMA in aortic sx Tx
-stop ATB
Ix -oral metro=1st line (10 d)
Film -oral vanco=2nd line
-thumb printing -vanco enema
(mucosal edema,submu.hmg) -recurrent=longer (up to 1 mo)
CT Fulminant colitis
-nonspecific colonic wall thickening -total colectomy c end ileostomy
-pericolic fat stranding
Angiography Others infectious colitis
-not helpful Common
-rare major a.occlusion -e.coli,campylobacter jejuni,yersinia,
Sigmoidoscope samonella,shigella,gonorrhea
-dark,hmg mucosa -ameba,cryptosporidium,giadia
-hi-risk to perforate -HIV,HSV,CMV
-relative C/I Uncommon
BE -TB,syphilis,actinomycosis
-C/I in acute phase -fungi

Tx Radition proctitis
-major can medical tx -bleeding formalin packing
-rest bowel,broad ATB -must sx colostomy/ proctocolectomy
-correct low flow stage
-colonoscopy after recovery
:evaluate stricture
:r/o other cause
-fail med=sx exploration
:resect necrotic bowel
:avoid primary anas
:may be 2nd look operation

Sequele
-stricture 10-15%
-chronic segmental ischemia 15-20%
 Colorectal-anus short note by S.Wichien (SNG KKU)

Colon injury Iatrogenic inj

Grading 1.intraop
Gr1=contusion -pelvic operation
Gr2=LW<50%circum -must early recognition
Gr3=LW>50%circum -little contaminate primary repair
Gr4=transaction -delay dx sig.peritonitis/sepsis
Gr5=tissue loss Tx fecal diversion, repeat exploration
2.BE
3 concepts method -rare
1.primary repair -intraperitoneum Sx
-lateral suture (grade 2) -extraperitoneum NOM
-resect c ileocolos /colocolstomy (grade 3) 3.colonoscopy
-running single layer -perforation
-safe & effective in all penetrating inj -<1%of procedure
2.end colostomy Tx
-damage control sx depend on
3.primary repair+diverting ileostomy 1.size perforation
-hi risk pt tumor/XRT/age/med condition 2.duration of time since inj
local FB/impair bl.supply/mesen.vv damage 3.condition of pt
shock/hmg>1000cc/onset>6hr -signi contaminate/delay dx/unstable pt
prox.diversion+/-resection
Rectum inj
Grading Anal sphincter injury
Gr1=contusion cause
Gr2=LW<50%circum -obstetric traummost common
Gr3=LW>50%circum -hemorrhoidectomy
Gr4=extend to peritoneum -sphincterotomy
Gr5=devascularized segment -abscess drainage
-fistulotomy
Intraperitoneum part -penetrating/blunt inj
-Tx as colon inj Ix
-primary repair or Hartmann -anal manometry
-electromyography(EMG)
Extraperitoneum part -endoanal u/s
Tx=4D Surgical repair
1.Diversion A wrap around sphincteroplasty
2.Direct repair (if can) -most common
3.Drainage (?) -mobilize divided sphincter m.
-presarcal w penrose drain -reapproximate without tension
-along Waldeyer fascia Postanal intersphincteric levatorplasty
-via perianal incision -levator ani m.is approximate to
4.Distal wash out (not used now) restore anorectal angle
-puborectalis/ext sphincter are tighten
Intestinal diversion with suture
1.sigmoid loop colostomy Gracilis m.transposition
2.loop ileostomy -sig.loss sphincter m.
Sigmoid colostomy -fail prior procedure
1.adequate mobilization Artificial anal sphincter
2.maintain common wall of -inflate silastic cuff
prox & distal limb above skin with Sacral n.stimulation
one half inch nylon rod
3.longitudinal incision in tenia coli
4.immediate maturation in OR
 Colorectal-anus short note by S.Wichien (SNG KKU)

Polyps B.Peut-Jeghers synd

1.Neoplastic polyps -polyposis small bowel,colon,rectum
-adenomatous polyps -melanin spot on buccal mucosa,lips
-dysplastic -may ca
-risk ca--size + type of polyps Sx--symptom,develop adenomatous
Size--polyps<1cm--rare ca
Type C.Cronkite-Canada synd
-Tubular adenoma - ca 5% -GI polyposis c alopecia,
-Villous adenoma - ca 40% cutaneous pigmentation,
-tubulovillous - ca 22% atrophy fingernail/toenail
-serrated polyp-ca 10% -diarrhea,n/v,malabsorp
:adenomatous+hyperplastic polyp -prot-losing enteropathy
:BRAF mutation -sx for c/p--obstruction
Malignant polyp
Size>2cm D.Cowden synd
Margin<2mm -AD
Kudo3 -harmartomatous
Haggitt4 -facial trichilemmomas,breast ca,
Haggitt thyroid dz,GI polyps = typical synd
0-Tis-mucosa
1-mm into submu—head 3.Inflammatory polyps
2-neck -pseudopolyps
3-stalk -inflam bowel dz
4-below stalk (LN 12-25%) -amebic/ischemic/schisto colitis
Kudo -not ca
Sm1-upper 1/3 submu -but can't distinguished adenomatous
Sm2-middle 1/3 submu polyps,so should be removed
Sm3-lower 1/3 submu
Tx 4.Hyperplastic polyps
-snare excision--pedunculate P -usually <5mm
-saline lift+piecemeal snare--sessile P -hyperplasia ,without dysplasia
Surveillance s/p endo Tx -large polyps >2cm--slightly risk ca
-scope 3 mo q 6 mo*2 yr q 2yr

2.Hamatomatous polyps
-juvenile polyps
-not usually premalignancy
-childhood
-common symptom
:bleeding,intussus,obstruction

A.familial juvenile polyposis

-AD
-100 polyps in colon,rectum
-may ca
-anaul screening age 10-12 yr
Tx
-spare rectum :total colectomy c
ileorectal anastomosis
-total proctocolectomy,ileal pouch,
anal reconstruction
 Colorectal-anus short note by S.Wichien (SNG KKU)

Pre-op evaluation Configuration

-colonoscopy End to end
:synchronous lesion -same caliber
:up to 5% of pt -colocolostomy,small bowel anasto
-PR End to side
-proctoscope c bx -one limb of bowel larger than other
-endorectal u/s -in chronic obstruction
-CXR Side to end
-abdo./pelvis CT -prox.bowel smaller than distal
-obstructive symp -ileorectal anastomosis
:avoid mech.bowel preparation -less bl.supply than end to end
-PET Side to side
-CEA = follow up -antimesen of two segment
-ileocolic,small bowel anas
Pre-op preparation
1.Bowel preparation Technique
-mechanical bowel preparation Hand suture
:polyethylene glycol (PEG) solution -single layer
:sodium phosphate solution :running or interrupt
:drink large volume -double layer
-antibiotic prophylaxis :inner=continue
:neomycin 1 gm :outer=interrupt
:erythromycin 1 gm/metro 500mg -permanent or absorb suture

2.stomal planning Stapled technique

-consult enterostomal(ET)nurse
-educated
-stoma siting : pre-op mark
3.ureteral stent
-identify ureter intraop
-inflam/phlegmon inc risk of ureter inj
during mobllize sigmoid colon
-linear cutter stapling device
:end to end anastomosis
-circular stapling device
:end to end,end to side,side to end
-useful in low rectal/anal canal anas
that hand sew difficult due to pelvis

Anastomosis
-highest risk of leak/stricture in
:distal rectal or anal canal
:irradiated/disease bowel

Colectomy
Ileocolic resection
-resect terminal ilium,cecum,appendix
-ileocolic crohn dz
-benign lesion or incurable ca
-if curable ca,more radical resection,
such as rt hemicolectomy
-ligated ileocolic vv
-1°anastomosis between distal small
bowel and ascending colon
Rt colectomy
-for curative intent resection of
proximal colon ca
-ligated ileocolic,rt colic,
rt br of middle colic vv
-10 cm of terminal ilium are resected
-primary ileal transverse colon anas
Extend rt colectomy
-for curative intent resection of
hepatic flexure/prox transverse colon
-ligate middle colic vv at their base
-rt colon,prox tv colon are resected
-primary anas at ilium-distal tv colon
Transverse colectomy
-lesion in mid,distal tv colon
-ligate middle colic vv
-colocolonic anastomosis
Lt colectomy
-lesion confined to distal tv colon,
splenic flexure,descending colon
-ligated lt br of middle colic vv,
lt colic vv,1st br sigmoid vv
-colocolonic anastomosis
Extended lt colectomy
-lesion in distal tv colon
-lt colectomy+extend include rt br of
middle colic
Sigmoid colectomy
-sigmoid lesion
-ligated sigmoid br of IMA
-resected to level of peritoneal reflect
-anas at descending c./upper rectum
-full mobilization of splenic flexure to
create tension free anastomosis
Colorectal-anus short note by S.Wichien (SNG KKU)
Total Colectomy
-fulminant colitis
-FAP
-peserved sup rectal a.
-ileorectal anastomosis
-if anas is contraindicate,an end
ileostomy is created and remaining
sigmoid or rectum as mucus fistula or
hartmann pouch
Subtotal colectomy
-distal sigmoid vv are left
-anas ilium-distal sigmoid colon
Proctocolectomy
Total protocolectomy
-colon,rectum,anus are removed
-ileum to skin=ileostomy
Restorative proctolectomy
-ileal pouch anal anastomosis
-preserve anal sphincter m,anal canal
-anastomose of ileal reservoir to anus -
neorectum by anastomosis of
terminal ileum aligns to J,S,W
-J puch is simplest=most used
-most perform proximal ileostomy to
divert succus from create pouch to
minimize leak and sepsis
-ileostomy closed 6-12 wk later
Procedure in colorectal obstruction
1.colonic obstruction
Rt side/ prox transverse colon
1.low risk pt 1ºileocolic anastomosis
2.hi risk pt resection+ostomy
Lt side colon
1.resection without anastomosis
-proximal colostomy+Hartmann
2.resection+on table lavage+1ºanasto
3.subtotal colectomy+1ºanasto
-caecal perforate
-synchronous lesion
-massive distend colon
4.3 stage
-colostomy resection anastomosis
5.colonic stent
-C/I perforate/<4cm from AV/rt side
2.Rectal obstruction
Upper+middle rectum
-stent or transverse colostomy CCRT/LAR
Lower rectum
-sigmoid colostomy CCRT Sx
 Colorectal-anus short note by S.Wichien (SNG KKU)

Anterior resection APR

-resect rectum from abdo approach
High AR
-resect distal sigmoid, upper rectum
-mobilize rectum, not fully from sacrum
-ligated IMA at its base
-ligated IMV
-1°anastomosis end to end
Low AR
-lesion at upper/mid rectum
-mobilize rectosigmoid
-open pelvic peritoneum
-mobilize rectum from sacrum
-dissection anorectal ring
-Post : through rectosacral fascia
Ant : through Denonvilliers fascia to
vagina in women or seminal vesicle
and prostate in men
-anastomosis require mobilize of
splenic flexexure
Extend low AR
-lesion in distal rectum
-but several cm above sphincter
-moblize rectum as low AR
-but ant dissection is extended along
rectovaginal septum in women
distal seminal vesicle/prostate in men
- when risk of leakage is hi
should perform temporary ileostomy
-post operative fxn may be poor
des colon lack distensibility
reservoir fxn may compromise
colon J-pouch or coloplasty =Improve fxn
-Hx of sphincter damage or incontinence is
relative C/I for coloanal anastomosis
End colostomy should perform
-abdomioperineal resection
-remove entire rectum,anal,anus
-permanent colostomy
-procedure as extend low AR
-peritoneal dissection
:2nd surgeon
:excise anal c. c wide circum margin
TME
-sharp dissection under vision
-outside mesorectal fascia
-down to pelvic floor
-identified and preserve symp+parasymp
-adequate mesorectal excision= 5cm margin
Step
1.plane behind rot of pedicle package
2.plane ant to ANS
3.hi ligation
IMA=prox to left middle colic A
IMV=inf of pancreas
4.dissect Holy plane
post lat ant
5.divide lateral ligament
15% in lateral ligament
6.anterior dissection
include peritoneal reflection+Denoviller
ANS sparing TME
-sup hypogastric plexus ejaculation dysfxn
-inf hypogastric plexus ED&urine retention

Pouchitis
-inflam affect both ileoanal pouch and
continent ileostomy reservoir
-incidence 30-55%
-diarrhea,hematoczia,abdo.pain,fever
-dx=endo+bx
-ddx=infection,undx crohn dz
-etiology=unknown
-fecal stasis
-ATB=metro+/-ciprofloxacin
-some develop chronic pouchitis
salicylate/steroid enema
pouch excision
 Colorectal-anus short note by S.Wichien (SNG KKU)

Ostomy Complication
-temporary vs permanent -stoma necrosis (early post op)
-end on vs loop :tight fascial defect or
-located in rectus m.to minimize risk :skeletonizing the distal small bowel
of parastromal hernia -stoma retraction
-pt can see,easily manipulate :in obesity
-abdo should flat to prevent leak -skin irritation
-circular skin incision -obstruction
-subcu.dissected to ant rectal sheath -parastomal hernia
-sheath is incised in cruciate fashion :less than colostomy
-separated m. :resiting the stoma to contralat side
-incised post sheath -prolapse
-size of defect depend on bowel size :rare,late c/p
-should be as small as possible, :asso parastomal hernia
without compromise bl.supply -Continent ileostomy = valve slippage
-usually width of 2-3 finger
-closed incision and dress prior 2.Colostomy
maturing stoma to avoid contaminate -most as End colostomy > loop colos
-3-4 interrupt absorb suture are -loop colostomy >>more prolapse
placed through edge of bowel then -most = in left side
through serosa then through dermis -mature by Brooke fashion
(Brooke technique) -distal bowel as
:mucus fistula
1.Ileostomy :Hartman pouch
Temporary ileostomy -closure of colostomy require
-protect anastomosis for leakage laparotomy : end to end anas
-loop ileostomy
-with or without rod Complication
-divided loop prevent incomplete -colostomy necrosis
diversion that occur c loop ileostomy :skeletonize distal colon
-advantage=closure can be :tight fascial defect
accomplished without Tx
laparotomy,handsewn or stapled :suprafascia--expectant
anastomosis can be created and :below fascia--sx
return bowel to peritoneal cavity -retraction
-obstruction
Permanent ileostomy -parastomal hernia
-require after total proctocolectomy or :most common late c/p
in pt c obstruction -prolapse
-end ileostomy -less skin irritation than ileostomy
:Brooke end ileostomy -less dehydrate than ileostomy
:Continent ileostomy (by Kock)
internal ileal reservoir
nipple valve construct :continence m.
 Colorectal-anus short note by S.Wichien (SNG KKU)

Adenocarcinoma Spreading
Incidence 1.Regional LN
-most common malignancy in GI -most common
-men=female -node metas inc with tumor size, poorly diff,
-adenoma-carcinoma sequence dept of invade, lymphovas invade
-dept of invasion (T)
Risk factor :most signi predictor of LN spreading
1.aging > 50yr :Tis = no node metas
2.hereditary :T1,2 = node metas 5-20%
-80%sporadic 20%fam.hx :T3,4 = node metas >50%
-APC gene defect -number of node asso.distant ds
3.environments ->=4 node : poor prog
-animal fat diet,low fiber -upper rectum
-hi-sat or polyunsaturated fat :along sup.rectal vv to IMA
-alcohol -lower rectum
-vit A,E,C,ca,selenium=dec risk :middle rectal vv
4.inflammatory bowel :inf rectal vv to int illiac node
-10yr--inc 2%
20yr--inc 8% 2.Hematogenous
30yr--inc 18% -most common = liver
5.other -via portal venous system
-smoking,ureterosigmoidotomy -risk of hepatic metas
acromegaly,pelvis irradiation :tumor size/ tumor grade
-pulmo.metas rarely occur in isolate
Genetic defect
Normal epi>>APC>>dysplastic epi>>early Staging
adenoma>>K-ras>>intermediate T1-invade submucosa
adenoma>>DCC/DPC4>>late T2-invade mucularis propia
adenoma>>p53>>carcinoma>>other T3-invade into pericolorectal tissue
change>>metas T4a-visceral peritoneum, T4b-invade organ
N1-1-3 LN
APC-tumor suppressor gene N1a-1, N1b-2-3
K-ras-proto-oncogene N1c-no LN but tumor in subsero/mesen
DCC-tumor suppressor gene N2->=4 LN
p53-tumor suppressor gene N2a-4-6, N2b->=7
M1a-1 organ, M1b->=2 organ
Genetic pw--2 major pw
1.LOH pw--80% *node is single most important prog.factor
-chromosome deletion and
tumor aneuploidy
2.RER pw--20%
-Replication Error pw
-missmatch repair pw
-asso microsatellite instability--MSI

Familial colorectal ca
Risk of ca
-no fam.hx 6%
-one 1st degree 12%
-two 1st degree 35%
 Colorectal-anus short note by S.Wichien (SNG KKU)

Ca colon.Tx Follow up
Pre-op -most recur within 2yr
-Colonoscopy -colonoscopy within 12 mo
:synchronous lesion--5% of pt if normal,repeat q 3-5 yr
-endorectal u/s -CEA q 2-3 mo for 2 yr
:assess T N -CT scan in CEA elevate,not routine
-CT chest/abdo/pelvis
-CEA Screening
Average risk
Objection -50yr
-remove 1°tumor along with -annual FOBT
its lympovascular supply -flex.sigmoidoscope q 5yr or
:lymph along a. BE q 5 yr or
:bowel resection depends on vv are Colonoscopy q 10 yr
supplying segment involved with ca Adenomatous polyps
-resect adjacent organ -50yr
:omentum -colonoscopy at 1st dx then in 3yr
-if can't remove all tumor Colorectal ca
:palliative procedure -at dx
-pre tx colonoscope then
Stage 0 (TisN0M0) 12 mo after curative resection then
-no node metas colonoscopy after 3yr then q 5yr
-completely remove endoscopic FAP
-follow colonoscopy -10-12yr
-annual flex.sigmoidoscope
Stage1 (T1 N0 M0) -EGD q 1-3yr after polyps appear
(malignant polpys) Attenuated FAP
Pedunculate polyps -20yr
-in head polyp--can endoscopic tx -annual flex.sigmoidoscope
-lymphovas.invasion,poorly diff, -EGD q 1-3yr after polyps appear
tumor within 1mm msrgin, HNPCC
invade submu -20-25yr
:segmental colectomy -colonoscopy q 1-2 yr
-endometrial aspi.bx q 1-2yr
Stage1 and 2 (T1-3 N0 M0) Fam.colorectal.ca
(localized colon ca) (1st degree relative)
-major=cure c sx -40 yr or 10 yr before the age of
-adjuvant CMT for select pt c stage2 youngest affect
:young pt,tumor c hi-risk histo.finding -colonoscopy q 5yr

Stage3 (anyT N1 M0) Surveillance

(LN metastasis ) Hx+PE+CEA
-recommend adjuvant CMT -q 3 mo * 2 yr
-5-FU base regimen c leucovorin -q 6 mo until 5 yr
Colonoscope
Stage4 (anyT anyN M1) -1 3 5 yr
(distant metas) -if no pre-op should s/p sx 3-6 mo
-all require adjuvant CMT CT scan
-can't cure by sx -q 1yr * 3 yr
-palliative
 Colorectal-anus short note by S.Wichien (SNG KKU)

Ca rectum.Tx stage0 (Tis N0 M0)

-more difficult to resect neg margin -Transanal excision
-because anatomic limit of pelvis -1 cm margin
-local recurrence higher than colon
stage1 (T1-2 N0 M0)
Local tx -localized rectal ca
¤distal 10 cm of rectum can transanal -local excision:local recur hi(20-40%)
Transanal excision -radical resection:recommend
-noncircum,benign,villous adenoma -in refuse radical sx
-can T1,some T2 :local excision
-can't LN--may understage pt :adjuvant chemoradiation
Transanal Endoscopic microsx(TEM) :improve local recurrence
-higher lesion(up to 15cm)
Ablative technique stage2 (T3-4 N0 M0)
-electrocautery,radiation -localized rectal ca
-disvantage=no patho specimen 1.preop staging
2.CCRT 4-6 wk
Radical resection 3.Sx
-remove involve segment, distal margin 2 cm
lymphovascular supply TME margin 2mm
-2cm distal margin ANP
Total mesorectal excision(TME) sphincter preserve if >= pelvic floor 1 cm
-sharp dissection anatomic plane 4.post op CRRT
-complete resection rectal mesentery stage 2a, LN +ve
-upper rectum/rectosigmoid
:partial mesorectal excision stage3 (anyT N1 M0)
:5cm distal tumor=adequate -node metas
-extensive involvement of pelvic organ -chemoradiation pre or post op for
may require pelvic exenteration node+ve rectal ca
:APR -neoadjuvant>>sx
:en bolc resection
(ureter,BD,prostate or uterus/vg) stage4 (M1)
:colostomy,ileal conduit -palliative procedure
:sacrectomy upto S2-3 jxn -avoid morbid procedure
-intraluminal stent
-diverting colostomy
 Colorectal-anus short note by S.Wichien (SNG KKU)

CA rectum Sx Complication s/p rectum Sx

1.Sphincter saving procedure 1.ureter injury
Procedure Mechanism of inj
1.AR 1.hi ligation of IMA 1ºrepair
-intraperito colorectal anastomosis 2.sigmoid mobilization 1ºrepair/Boari flap
2.LAR 3.anterolat dissection re implant
-extraperito colorectal anastomosis Suspect in intraop
3.ultralow AR -iv indigo carmine/ methylene blue
-just above pelvic floor -post op RP
4.intersphincteric resection
-divide full thickness of IAS 2.urethral inj
-1-2cm distal from tumor +/- frozen section -dissection APR
-coloanal anstomosis -don t dissect across transverse perineal m
-Tx 1ºrepair over foley retain 2-4 wk
Reconstruction
1.end to end 3.anastomosis leakage
-loss rectal reservoir Prevention
-LAR synd trenesmus, frequency, inconti -good blood supply
2.colonic J pouch -tension free anastomosis
-6-8 cm pouch -complete donut ring
-dec LAR synd -air test
3.coloplasty Free leakage Tx
-take down anastomosis hartmann
Protective ileostomy I/C -1ºanasto+diverting ostomy+pelvic drain
1.pre op XRT/ CMT (low contaminate+small defect)
2.ultralow anastomosis Contained leakage or abscess Tx
3.incoplete donut ring -small abscess ATB iv
4.malnutrition, immunosup, pelvic abscess -large abscess PCD
-continue leakage PCD+diversion ostomy
2.APR
I/C 4.anastomosis bleeding
1.tumor invade ext sphincter/ pelvic floor -staple > handsewn
2.sphincter incompetence
3.poor colonic vasculariztion 5.post op ileus
-open sx > 5 d
3.local excision -lap sx > 3 d
I/C Tx
-T1, well diff, no LVI -enhanced recovery program
-N0 -peripheral µ opioid antagonist
-mobile :Alvimopam (approve 15 dose)
-< 3cm :12 mcg o 30 min pre op
-<30% circum :12 mcg o bid * 7 d
->3mm margin
 Colorectal-anus short note by S.Wichien (SNG KKU)

Anal tumor Verrucous ca

-uncommon -Buschke-Lowenstein tumor or
-2%of colorectal malignant Giant condyloma accuminata
-aggressive of condy.accuminata (HPV 6,11)
Divided into -not metas
1.anal canal -Tx of choice--wide local excision
-puborectalis to AV
-lymph drainage Basal cell ca
:sup.rectal IM node -rara of anus
:middle,inf.rectal int.illiac node -as skin
2.anal margin -raise,pearly edge,central ulcer
-distal to dentate line -slow growing tumor
-5 cm around AV -rare metas
-lymph drainage -wide local excision
:inguinal node -large lesion=radical resection,RTX
:if 1°are block sup.rectal
Adenocarcinoma
Anal intraepi.neoplasia (AIN) -extremely rare
-bowen ds -spread from lower rectal ca
-hi-grade squa. intraepi lesion--HSIL -may from anal gland/chronic fistula
-sq.cell ca in situ -Tx of choice APR+WLE of perineum
-precursor to invasive sq.cell ca Paget dz
-plaque like lesion -adenocarcinoma in situ
-as CIN : acetic acid,Lugol solution -apocrine gland
-asso HPV 16,18 -plaque like
-asso HIV,homosexual men -indistinguish from Bowen dz
-hi-reso anoscopy--abnor telangiec -paget cell
Tx -asso synchronous GI adenoca
-resection or ablation complete assess GI tract
-hi recurrent,require closed f/u -wide local excision 1 cm
:pap smear q 3-6 mo
Melanoma
Epidermoid carcinoma -rare
1.sq.cell ca -1-2% of melanoma
2.cloacogenic ca -S-100
3.transitional ca -5yr survive <10%
4.basaloid ca -at dx often deep invade, metastasis
-slow growing -Tx of choice WLE
-anal/perianal mass
-pain,bleeding
-inguinal node=poor prog
Tx
SCC of anal canal
-non keratinized
-Nigro protocol (5FU,MMC,3000cGy) > APR
SCC of anal margin
-keratinized
-as sq.cell ca in skin
-WLE 2 cm

Rare colorectal tumor
Carcinoid
-25% in rectum
-risk malignancy inc with size
-tumor>2cm :60% have metas
-less vasoactive in other location
-have syndrome--have liver metas
-in prox.colon
:less common
:more likely to be malignancy
-med=somatostatin(octreotide),INF
Small
-locally resect
Large/invade muscular
-more radicak sx
Carcinoid carcinoma
-adenocarcinoid
-both carcinoid and adenoca
-hx=more closely adenoca
-common regional/systemic metas
-tx as adenoca
Lipoma
-most common in submucosa
-benign
-<2cm=rarely cause bleed,obstr,intus
-small asymp=not sx
-larger
:colonoscopic resection
:colotomy c enucleation
Lymphoma
-10%of GI lymphoma
-rare in colon/rectum
-cecum is most involve
(spread from terminal ileum)
-bleeding,obstruction
-Tx of choice = bowel resection
-adjuvant cmt upon stage
Leiomyoma
-smooth m.tumor
-most common in upper GI
-most=asymp
-large lesion=bleed,obstruct
-difficult to distinguished from
leiomyosarcoma,should resect
->5cm--radical resection,
(because risk of malignancy)
Colorectal-anus short note by S.Wichien (SNG KKU)
Leiomyosarcoma
-rare in GI
-rectum is most common
-radical resection
Retrorectal tumor
-presacral tumor
-ant--rectum post--presacral fascia
lateral--endopelvic fascia
-upper 2/3 of rectum and sacrum
-contain embryologic remnant
(neuroectoderm,notocord,hindgut)
-most common=congenital
-lower back/pelvic/leg pain
-GI symptom
-PR=palpable lesion
-MRI pelvis=most sense/spec
-myelogram in CNS involve
-bx not indicate,if lesion resectable
:infection,seeding
Cyst
-dermoid/epidermoid--ectoderm
-enterogeneous cyst--primitive gut
-ant meningocele/myelomeningocele
:scimitar sign = pathognomonic
(sacrum c round, concave border
without bony destruction)
Solid
-teratoma--germ cell
-chordoma--notochord
:most common malig in this region
:bony destruction
-neurofibroma,neurilemoma
ependymoma,ganglioneuroma
-osteoma,bone cyst
osteogenic sarcoma
ewing sarcoma,giant cell T
chondromyxosarcoma
Tx
-sx resection
Hi-lesion--transabdo approach
Low-lesion--transacral

Familial Adenomatous Polyposis
-1% of colorectal adenoca
-AD
-APC gene mutation
-APC gene testing (+ve in 75%)
-located on chrom 5q
-risk ca 100% by age 50 yr
Screening
-flex.sigmoidoscope
:1st degree relative--age 10-15 yr
:q 2 yr until 34 yr
:q 3 yr until 44 yr
:then 3-5 yr
-EGD
:at 25-30yr q 1-3yr
:adenoma anywhere in GI
:duodenum >> periampullary ca
Rx
4 factors affect choice of Sx
-age
-severity of symptom
-extend of rectal polyposis
-location of ca,desmoid tumor
1.total abdo.colectomy
-ileorectal anastomosis
-¤surveillance rectum
2.total proctocolectomy
-end ileostomy (Brooke) or
continent ileostomy (Kock)
-large abandon--success of 1
3.restorative proctocolectomy
-ileal pouch anal anastomosis
+/- temporary ileostomy
Med
-admin cox-2 inh (celecoxib,sulindac)
may slow develop polyps
Extraintes manifestation
-congen.hypertrophy of retinal
pigment epithelium
-desmoid
-epidermal cyst
-mandibular osteoma (Garder synd)
-CNS tumor (Turcot synd)
Colorectal-anus short note by S.Wichien (SNG KKU)
FAP attenuated (AFAP)
-polyps < 100
-later in life age
-APC mutation AD (30% of pt)
-MYH mutation AR
-10-100 polyps--dominant rt colon
->50%--ca clon--average 50yr
-duodenal polyposis
Tx
-total colectomy+IRA
-if have rectal lesion snare+follow colono
HNPCC (Lynch syndrome)
-Hereditary Nonpolyposis Colon Ca
-AD
-error in mismatch repair
-develop ca at early age--40-45 yr
-not Ca 100% as FAP
-synchronous lesion = 40
Lynchs syndrome
1=only colon
2=GI/KUB/Gyne
3=skin lesion
4=Turcot syndrome
Extracolonic malignancy
-endometrial--most common
-ovarian, panc, stomach, smb, biliary, uro
3-2-1-0 rules Amsterdam criteria
->=3 relative dx--HNPCC
one of whom is 1st degree relative
-at least 2 generations
-at least 1--dx <50yr
-no FAP
Screening
-screening colonoscopy 20-25yr or
10yr younger than youngest age
at diagnosis in family
-hi risk of endometrial ca
:TVS or endometrial aspiration bx
:after 25-35yr
Sx
-total colectomy+IRA
40% risk of develop 2°colon ca
in adenoma/colon ca
anaul proctoscope >> risk ca rectum
-prophylactic hysterectomy c BSO
in complete childbearing